Cryoprecipitate Research Articles

Empiric Cryoprecipitate Transfusion in Patients with Severe Hemorrhage: Results from the US Experience in the International CRYOSTAT-2 Trial.

Hypofibrinogenemia has been shown to predict massive transfusion and is associated with higher mortality in severely injured patients. However, the role of empiric fibrinogen replacement in bleeding trauma patients remains controversial. We sought to determine the effect of empiric cryoprecipitate as an adjunct to a balanced transfusion strategy (1:1:1). This study is a subanalysis of patients treated at the single US trauma center in a multicenter randomized controlled trial. Trauma patients (more than 15 years) were eligible if they had evidence of active hemorrhage requiring emergent surgery or interventional radiology, massive transfusion protocol (MTP) activation, and received at least 1 unit of blood. Transfer patients, those with injuries incompatible with life, or those injured more than 3 hours earlier were excluded. Patients were randomized to standard MTP (STANDARD) or MTP plus 3 pools of cryoprecipitate (CRYO). Primary outcomes included all-cause mortality at 28 days. Secondary outcomes were transfusion requirements, intraoperative and postoperative coagulation laboratory values, and quality-of-life measures (Glasgow outcome score-extended). Forty-nine patients (23 in the CRYO group and 26 in the STANDARD group) were enrolled between May 2021 and October 2021. Time to randomization was similar between groups (14 vs 24 minutes, p = 0.676). Median time to cryoprecipitate was 41 minutes (interquartile range 37 to 48). There were no differences in demographics, arrival physiology, laboratory values, or injury severity. Intraoperative and ICU thrombelastography values, including functional fibrinogen, were similar between groups. There was no benefit to CRYO with respect to post-emergency department transfusions (intraoperative and ICU through 24 hours), complications, Glasgow outcome score, or mortality. In this study of severely injured, bleeding trauma patients, empiric cryoprecipitate did not improve survival or reduce transfusion requirements. Cryoprecipitate should continue as an "on-demand" addition to a balanced transfusion strategy, guided by laboratory values and should not be given empirically.

Impact of early and empirical cryoprecipitate administration on the transfusion requirements in trauma patients with hemorrhagic shock

Abstract BACKGROUND: Fibrinogen is the earliest coagulation factor falling to the critical levels in severely bleeding trauma patients. Early fibrinogen supplementation in these patients has been recommended to improve the patient outcomes. However, its role in reducing the overall transfusion requirement remains equivocal. AIMS: This study aimed to evaluate the effect of early cryoprecipitate (CRYO) administration on the transfusion requirement and the coagulation assays in trauma patients with hemorrhagic shock. SETTINGS AND DESIGN: An interventional study was conducted in two phases at level I trauma center. During the 1st phase (Group I), patients received blood components in accordance with current practices, whereas in the 2nd phase (Group II), patients received an additional CRYO (pool of 6 units) empirically within 90 min of admission. METHODS: Demographics, clinical, injury characteristics, transfusion requirements, blood counts, and coagulation assays were assessed for both the study groups. STATISTICAL ANALYSIS: The comparative analysis was done for blood component utilization and coagulations assays (prothrombin time, activated partial thromboplastin time, and fibrinogen levels) in both study groups. RESULTS AND CONCLUSIONS: A total of 50 patients in Group I and 51 patients in Group II were recruited. Demographics, clinical, injury characteristics, and laboratory investigations were comparable, except for heart rate, blood pressure, and injury scores. Significant reductions in red blood cell and platelet transfusions were observed, whereas the fresh-frozen plasma transfusions remained unaffected. The results of coagulation assays at 18–24 h were similar for both groups. Although no significant differences in fibrinogen levels were observed despite CRYO administration, decreased requirement for transfusions indicated an improved hemostasis in CRYO group.

Efficacy of prompt administration of cryoprecipitate in severe postpartum hemorrhage of preeclampsia patients.

Cryoprecipitate (CRYO) is a concentrated preparation of coagulation factors formulated from fresh frozen plasma (FFP), which can replenish coagulation factors rapidly. Preeclampsia (PE) is frequently associated with postpartum hemorrhage (PPH), and the rapid replenishment of coagulation factors is vital in the management. We conducted a retrospective cohort study to determine the efficacy of administering CRYO irrespective of fibrinogen levels in patients with PE who experienced severe PPH. Patients with PPH accompanied by PE and those who required red blood cell (RBC) transfusion were included. Cases were divided into two groups: those treated with CRYO (N = 16) and those not treated with CRYO (N = 10). The total transfusion volume, blood loss before and after transfusion initiation, duration of hospitalization, presence of pulmonary edema, and performance of either interventional radiology or hysterectomy were compared. The median fibrinogen levels before transfusion were 2.24 and 2.34 g/L in the CRYO group and the not using group, respectively. Although blood loss before transfusion was comparable between the two groups, blood loss after transfusion was significantly less in the CRYO group (median: 520 vs. 2352 mL, p = 0.015), as well as the total blood loss (median: 2285 vs. 3825 mL, p = 0.005) and total transfusion volume (median: RBC 6 vs. 16 U, p = 0.01, FFP 10 vs. 20 U, p = 0.017). Prompt replenishment of coagulation factors using CRYO to patients with PE who experience severe PPH could decrease further bleeding.

Overestimation of fibrinogen concentration in cryoprecipitate by repeated freeze-thawing with long thawing period as used in the Clauss method.

Cryoprecipitate (CRY) is widely used for treating acquired hypofibrinogenemia. During our study to determine an optimal preparation method, we noticed that the measurement of fibrinogen concentration in CRY had a risk of overestimation. We analyzed this condition and mechanism. CRY was prepared from fresh frozen plasma (FFP) under four conditions: A, 30 h thawing time, 2 cycles; B, 24 h thawing time, 2 cycles; C, 30 h thawing time, 1 cycle; and D, 24 h thawing time, 1 cycle. Then, fibrinogen concentrations in CRY and cryosupernatant (CS) were measured by the Clauss method. Purification (CRY/CRY+CS) and recovery (CRY/FFP) rates in CRY prepared under 2-cycle conditions were higher than those under 1 cycle. However, recovery rates often exceeded 100%, particularly in the case of CRY prepared under A condition, and fibrinogen concentrations calculated by direct measurement were higher than those indirectly calculated from FFP and CS, suggesting an overestimation of fibrinogen values. The level of soluble fibrin monomer complex was considerably higher in CRY prepared under A than under D condition, indicating that CRY adopted a hypercoagulated state. We further found that repeated thawing/freezing increased fibrinogen values as measured by the Clauss method while mechanical vortexing did not. Our findings suggest that direct assessment of fibrinogen contents in CRY prepared by repeated freeze-thawing with a longer thawing period presents a higher risk of overestimation. For the purpose of quality control, we propose an alternative method to indirectly estimate fibrinogen concentrations in CRY from those of CS and FFP.

Management of Severe Hemophilia A: Low-Dose Prophylaxis vs. On-Demand Treatment.

Prophylactic clotting factor infusion regimens to prevent bleeding and joint deformity has become the standard of care in severe hemophilia A patients. To assess low-dose factor prophylaxis in our population as an alternative approach to managing severe hemophilia A. A prospective cohort study that included 68 hemophilia A patients divided into two groups, i.e., Prophylaxis and on-demand. The two groups were compared for annualized bleeding rate (ABR), hospitalization, units of factor VIII (FVIII) infused, or plasma products transfused, i.e., fresh frozen plasma (FFP) and cryoprecipitate (CP), and development of FVIII inhibitors. Of the 68 patients recruited in this study, 25 (36.7%) were in the prophylaxis group, and 43(63.3%) were in the on-demand group. The on-demand group presented a higher median-IQR ABR [8(20-3) vs. 5(10-1.5), p-value 0.024], several hospitalizations (39.7% vs. 0, p-value0.001), and inhibitor development (9.3% vs. 0, p-value 0.289) compared to the prophylaxis group. The prophylaxis approach demonstrated a significant negative correlation of ABR with FVIII prophylaxis (r=-0484, p=value=0.014). Moreover, no hospitalizations or inhibitor development was observed in the prophylaxis group. The estimated annual consumption of FVIII was 328 IU/kg/year in the on-demand group and 1662.6 IU/kg/year in the prophylaxis group. However, a highly significant difference in plasma product utilization was observed between the two groups, i.e., p-value <0.001 and 0.038 for FFP and CP, respectively. Low-dose factor prophylaxis resulted in improved outcomes compared to on-demand treatment in terms of ABR, joint bleeding, hospitalization, and the development of inhibitors. This treatment approach should be adopted as an economically feasible alternative to high-dose Prophylaxis in resource-constrained countries.

Immediate use cryoprecipitate products provide lasting organ protection in a rodent model of trauma/hemorrhagic shock and prolonged hypotensive resuscitation.

Cryoprecipitate (CP) can augment hemostasis after hemorrhagic shock (HS). Similar to fresh frozen plasma (FFP), CP may provide short-term endothelial protection. We tested a new 5-day postthaw CP (5-day pathogen-reduced cryoprecipitate [5PRC]) and lyophilized pathogen-reduced cryoprecipitate (LPRC) to overcome challenges of early administration and hypothesized that 5PRC and LPRC would provide lasting organ protection in a rodent model of HS. Mice underwent trauma/HS (laparotomy then HS), mean arterial pressure (MAP) 35 × 90 minutes, and then 6 hours of hypotensive resuscitation (MAP, 55-60 mm Hg) with lactated Ringer's solution (LR), FFP, CP, 5PRC, or LPRC and compared with shams. Animals were followed for 72 hours. Organs and blood were collected. Data are presented as mean ± SD and analysis of variance with Bonferroni post hoc. Mean arterial pressure was comparable between experimental groups at baseline, preresuscitation, and 6 hours per protocol. However, volume needed to resuscitate to target MAP over 6 hours was less than half for CP, 5PRC, LPRC, and FFP compared with LR, suggesting that CP products can serve as effective resuscitative agents. Mean arterial pressure at 72 hours was also significantly higher in the CP, 5PRC, and FFP groups compared with LR. Resuscitation with CP, 5PRC, and LPRC provided lasting protection from gut injury and enhanced syndecan immunostaining comparable with FFP, while LR mice demonstrated persistent organ dysfunction. Sustained endothelial protection was demonstrated by lessened lung permeability, while cystatin C was an indicator of kidney function, and liver aspartate aminotransferase and alanine transaminase returned to sham levels in all groups. Cryoprecipitate products can provide lasting organ protection comparable with FFP in a sustained rodent model of trauma/HS and hypotensive resuscitation. The availability of 5PRC and LPRC will allow for investigation into the immediate use of cryoprecipitate for severely injured patients. As lyophilized products such as cryoprecipitate become available clinically, their use has important implications for prehospital, rural, and battlefield usage.

Fresh frozen plasma and cryoprecipitate: Can we safely reduce their use in the NICU?

To study patterns of use of Fresh Frozen Plasma (FFP) and Cryoprecipitate (CRYO) in a level 4 NICU and assess what proportions were not supported by literature. single centered retrospective observational. Charts of neonates admitted between 1/1/2010 to 12/31/2017 to CT Children's level 4 NICU were reviewed. Transfusions were assigned as "supported" or "non-supported" based on available evidence. Groups were compared using T-tests and chi-squared analyses. of 4110 total admissions, 197 (4.8%) received a total of 461 transfusions (374 FFP, 87 CRYO). Only 59% of FFP and 60% CRYO were supported by literature. Within the "non-supported" group the largest category was neonates transfused prophylactically. A large proportion of transfusions administered to neonates was not evidence-based, suggesting there are opportunities for improvement in use of these products.

Analysis of Blood and Blood Component Wastage and its Reasons among Various Departments in a Tertiary Care Teaching Hospital in Southern India

Introduction: The main aim of many blood centers are to supply sufficient amount of safe blood and blood components whenever required. Shortage of blood may be due to low donation rate, inadequate storage, improper transportation and wastage at ward side. Wastage of blood can have a negative impact on blood transfusion services. Aim: To determine the rates of wastage of blood and blood components units at the ward side and identify the various reasons for wastage and explain the strategies to reduce the wastage rate. Materials and Methods: This retrospective study was conducted in the Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India from January 2018 to December 2020. The data was collected from the blood centre record. All blood and blood components issued during the study period were included in the study. The number, type and blood group of blood and blood components issued, the number of blood units wasted after issue, and the reason for wastage was collected. The collected data were entered in Microsoft excel and analysed using Statistical Package for the Social Science (SPSS) version 21.0. Descriptive statistics were performed as necessary. Results: During the study period, a total of 69198 units of blood and blood components were issued to different wards and operation theatres in the hospital. Among the total issues, 26863 (38.82%) were in the form of Packed Red Blood Cells (PRBC), 3968 (5.73%) in the form of Whole Blood (WB), 26069 (37.67%) in the form of Fresh Frozen Plasma (FFP), 11272 (16.29%) in the form of Random Donor Platelets (RDP), 933 (1.35%) in the form of Cryoprecipitate (CP) and 93 (0.13%) in the form of Single Donor Platelets (SDP). Among issued, 115 (0.17%) of blood and blood components were wasted with packed red cells accounting for 51 (44.35%). Among the various reasons, 43 (37.39%) was due to demise of patients before transfusion was initiated, followed by non requirement by the patients due to no loss/minimal loss blood during surgery 24 (20.87%). Majority of blood and blood components were wasted by the Department of Emergency Medicine (EMD) 36 (31.3%) followed by the Department of Neurology 20 (17.39%) and Orthopaedics 12 (10.43%). Conclusion: Implementation of proper blood transfusion policies and continuous educational programs in coordination with clinicians and staff nurses at ward side and operation theatres will help to decrease the blood wastage at ward side.

Validation of blood components transport through a pneumatic tube system

IntroductionUrgent blood component transfusions may be life-saving for patients in hemorrhagic shock. Measures to reduce the time taken to provide these transfusions, such as uncrossmatched transfusion or abbreviated testing, are available. However, transport time is still an additional delay and the use of a pneumatic tube system (PTS) may be an alternative to shorten the transport time of blood components. ObjectivesTo assess pneumatic tube system transportation of blood components based on a validation protocol. Methods: Pre- and post-transport quality control laboratory parameters, visual appearance, transport time and temperature of the packed red blood cells (RBCs), thawed fresh plasma (TFP), cryoprecipitate (CR), and platelet concentrate (PC) were evaluated. Parameters were compared between transport via pneumatic tube and courier. ResultsA total of 23 units of RBCs, 50 units of TFP, 30 units of CR and ten units of PC were evaluated. No statistically significant differences were found between pre- and post-transport laboratory results. There was also no difference in laboratory parameters between transport modalities (PTS versus courier). All blood components transported matched regulatory requirements for quality criteria. The temperature during transport remained stable and the transport time via PTS was significantly shorter than the courier's transport time (p < 0.05). ConclusionThe PTS was considered a fast, safe and reliable means of transportation for blood components, also securing quality prerequisites.

Splenic kaposiform hemangioendothelioma presenting as insidious consumptive coagulopathy

Splenic kaposiform hemangioendothelioma presenting as insidious consumptive coagulopathy

Effect of cryoprecipitate transfusion therapy in patients with postpartum hemorrhage: a retrospective cohort study

To evaluate the effect of cryoprecipitate (CRYO) transfusion in women referred for postpartum hemorrhage (PPH). This retrospective cohort study included patients with primary PPH referred to Gifu University Hospital between April 2013 and March 2020. We analyzed the effect of CRYO transfusion on fluid balance 24 h after the initial examination using a multivariable linear regression model adjusted for several confounding variables. To evaluate whether outcomes were modified by active bleeding, an interaction term of CRYO*active bleeding was incorporated into the multivariable model. We identified 157 women: 38 in the CRYO group (cases) and 119 in the control group. Fluid balance in the aforementioned period tended to decrease in the CRYO group compared with that in the control group (coefficient − 398.91; 95% CI − 1298.08 to + 500.26; p = 0.382). Active bleeding on contrast-enhanced computed tomography affected the relationship between CRYO transfusion and fluid balance (p = 0.016). Other outcomes, except for the overall transfusion requirement, were not significantly different; however, the interaction effect of active bleeding was significant (p = 0.016). CRYO transfusion may decrease the fluid balance in the first 24 h in PPH patients, especially in those without active bleeding.

Dr Judith Graham Pool and the development of cryoprecipitate.

Dr Judith Graham Pool and the development of cryoprecipitate.

Clinical Blood Utilization of Patients at Different Ages for a Hospital in Sichuan from 2017 to 2018

To analyze the use of blood products in patients at different ages. The clinical datas of the 10 784 patients transfused in Sichuan provincial people's hospital at 2017-2018 were retrospectively analyzed, and the basic condition of clinical blood using was statistically described. The patients were divided into the groups according to age and disease, then the use of various blood products in the patients with different diseases in different age groups was analyzed. The age of blood transfusion patients was mainly 40-80 years old, and the most common disease was tumor(about 28%). The average annual transfusion volumes of red blood cells(RBC) were 24 936.5 U, of platelets(PLT) were 3 795 therapeutic doses of plasma were 2 455 500 ml, of cryoprecipitate were 3 461.5 U in our hospital. Most patients with hematologic malignancies and liver cirrhosis were transfused with two or more blood productions. For the patients with hematologic malignancies, the irradiated RBC (76.4%), PLT (67.8%), and suspended RBC (59.9%) were commonly used. And for liver cirrhosis patients, the suspended RBC (64.2%) and fresh frozen plasma(FFP) (59.4%) were commonly used. For the patients with trauma and chronic kidney disease(CKD), the suspended RBC (95.7% and 91.5%, respectively) was commonly used. In hematologic malignancies patients, the transfusion volume of irradiated RBC, PLT and FFP in the patients aged ≥60 years old was lower than that in patients aged<60 years old (P<0.05); in trauma patients, the transfusion volume of suspended RBC in the patients aged ≥60 years old was lower than that in patients aged<60 years old (P<0.05). In hematologic malignancies, trauma and liver cirrhosis patients, the proportion of PLT and/or plasma transfusion in the patients aged ≥60 years old was lower than that in patients aged<60 years old (P<0.05), and the elderly patients were more likely to receive RBC transfusion only. There is a difference in the distribution of blood product between the patients aged<60 years old and ≥60 years old in the same disease, and it is more likely that the elderly patients (aged ≥60 years old) receive RBC transfusion only, and correction of hypoxia is a major clinical consideration, so blood using plans should be made according to the patient population, moreover, the different transfusion strategies should be developed for different population to maximize the efficiency of blood using.

Successful Treatment of Unremitting Gastro-Intestinal Haemorrhage & Rashes of Henoch-Schӧnlein Purpura with Colchicine & Cryoprecipitate: A Case Report

Severe gastrointestinal manifestations and rashes of Henoch Schonlein Purpura (HSP) may not always respond to prednisolone or other immunosuppressive agent. Though reduced factor XIII may play a role in gastrointestinal manifestations but its role in management of skin rashes is uncertain. Here, we reported a case treated with different immunosuppressive agents but didn`t respond. Thereafter, despite having the normal factor XIII assay, the unremitting GI symptoms and skin rashes, has improved after prescribing colchicines & infusion of Cryoprecipitate containing factor XIII.

An analysis of wastage of blood components in blood bank at tertiary care hospital

Context: Wastage of all blood components, including RBCs, platelets (PLT), and plasma, is an important issue for hospitals worldwide. Waste is not limited to blood products and is present throughout the health care system.1 Studies of systemic waste have examined the importance of workflows in the health care environment.2 and have focused on min im iz in g operational sources of waste when issuing a variety of medications. In many of these studies, relatively simple interventions resulted in marked reductions in wastage. The present study is designed to analyze the reason for the extent and wastage of whole blood and different blood components. By that we can minimize or prevent the wastage of blood and supply adequate amount of blood components to the patients whenever required for saving the lives.Aims and Objectives: The basic aim of this study isTo understand the extent of wastage of different blood components.To identify various causes of wastageMaterials and Methods: This is a retrospective and prospective study carried out in A D Gorwala Blood Bank, Shri Krishna Hospital, Karamsad after HREC approval, from 1st January 2015 to 31st December 2015. All the components, like whole blood unit (WBU), Red Cell Concentrate (RCC), Platelet Concentrate (PC),Fresh Frozen Plasma (FFP),Cryoprecipitate (CP), and Cryopoor plasma (CPP) except Single donor plate lete (SDP), wasted during this study period due to any reasons were included in the study.Statistical Analysis: It is an observational study so descriptive statistics is applied.Results: Age, gender, and blood group wastage of blood components were analysed and it was found that most common wastage was found in male donor between 18 to 30 years of a ge, in “ B” Positive blood group. In this study also reason for wastage of different blood components and components wise wastage reason also analysed. Most common component wasted was platelet concentrate due to short shelf life and due to 1st run reactivity in TTI testing.Conclusion: •The most component wasted was platelet concentrate due to its short expiry life followed by TTI (transfusion transmitted infection) reactivity after 1st run of ELISA.•To avoid wastage of blood components continued training of staff, involved in counseling of donor, phlebotomy and TTI testing along with inventory control regarding the stock position and requirement of different blood group is necessary.•Regular audit of transfusion of blood component by transfusion committee helps in reduction of blood wastage and also promotes its rational use.

Transfusion therapy optimization at an acute obstetric blood loss

Objective. To define the role of the cryoprecipitate (CP) and prothrombin complex concentrate (PCC) in the acute obstetric blood loss treatment via the assessment of the water sectors’ state, hemostasis, and frequency and severity of clinical manifestations of the multiple organ dysfunction syndrome (MODS).&#x0D; Materials and methods. 140 women had been examined (over the years 2006-2018), whose child delivery or early postnatal period (fourth stage of labor) had got complicated by an acute severe blood loss with a circulating blood volume deficit of 40 to 60 %. Based on the intensive treatment (IT) characteristics, the patients had been divided into three groups. In the group 1 (post-hoc analysis, n=50), a normal acute blood loss intensive treatment as per the relevant clinical protocols of the Health Ministry of Ukraine had been being provided. In the group 2 (n=44), an acute blood loss intensive treatment as per the abovementioned clinical protocols of the Health Ministry of Ukraine with use of the CP as the first-line drug had been being provided. In the group 3 (n=46), the PCC (Octaplex 20 IU/kg) had been added within the treatment. Thereat, there had been assessed such criteria as follows: RBC count, Hb, Ht, prothrombin index (PI), activated partial thromboplastin time, fibrinogen; the water sectors of the human body had been assessed noninvasively, via the integral impedance method; as well as the clinical signs of the MODS.&#x0D; Results and discussion. The use of the CP as the first-line drug at a dose of 8 to 10 units had enabled to get decreased the total volume of the infusion and transfusion media by 13.7 % (p&lt;0.05), and the total volume of the administered fresh frozen plazma (FFP) – by 12 % (p&lt;0.05) respectively. The adding of the PCC to the relevant IT guidelines had been resulting in a reduction of the total volume of the infusion and transfusion media by 24.5 % (p&lt;0.01), of the administered plasma volume – by 22 % (p&lt;0.01), and of the corpuscular volume – by 9.1 % (p&lt;0.05) respectively. Furthermore, a decrease in the vasopressor support rate (by 5.1 times, p&lt;0.01) and in the vasopressor support duration (by 1.5 natural days, p&lt;0.01), as well as in the adaptive lung ventilation rate and duration (by 5.7 times, p&lt;0.01), had been being observed; thereat, the number of the patients needing the use of the diuretics had been being reduced (by 2.9 times, p&lt;0.01), as well as the duration of their administration (by 1.7 natural days, p&lt;0.01 respectively). The PI and fibrinogen rate had been corresponding to the norms by the end of the 1st natural day of treatment.&#x0D; Conclusions. The use of the CP as the first-line drug in the IT of an acute obstetric blood loss ensures a verifiable lessening of need for the infusion and transfusion media. The PCC as the first-line drug prevents the development and progress of the coagulopathy at the treatment of an acute obstetric blood loss, what decreases the frequency and severity of clinical manifestations of the MODS credibly.

Treatment of bleeding in a patient with immune coagulopathy (acquired haemophilia A)

Objective. We are representing the case of acquired haemophilia A and analyze the timeliness and adequacy of treatment.&#x0D; Materials and methods. The subject of the study was immune coagulopathy with a factor VIII (FVIII) inhibitor – acquired haemophilia A.&#x0D; Results and discussion. Female, 33 years old, pregnancy II, urgent delivery. There was excessive bleeding in the early postpartum period, hemostatic therapy was provided. She hospitalized three times with recurrences of uterine bleeding. Vacuum aspiration of the walls of the uterine cavity was performed twice. After the third recurrence, blood loss of 1200 ml and ineffectiveness of conservative treatment, laparotomy and extirpation of the uterus was performed. Despite intensive care, the bleeding continued, the patient was transferred to the regional clinical hospital, where she was diagnosed with DIC syndrome, stage III, severe anemia. Three relaparotomies were performed, the source of bleeding was not found, there was excessive bleeding from the operating field. The total blood loss was 24,447 ml. Intensive infusion-transfusion therapy was continued, which gave unstable hemostasis. The patient received 12,060 ml of fresh-frozen plasma (FFP), 15,130 ml of erythrocytes, 600 ml of albumin 10 %, 20 doses of cryoprecipitate (CP), 16,000 U of activated prothrombin complex (APCC), 8 mg of recombinant activated factor VII (rVIIa), 8,000 U of prothrombin complex (PC). 16.1 BU/ml of inhibitor FVIII, FVIII &lt;1.0 %, activated partial thromboplastin time (APTT) – 146.1 s was detected on day 37. Within 30 days, blood loss was 10,608 ml; patient received 23,420 ml of FFP, 2,080 ml of erythrocytes, 17 mg of rVIIa, 19,000 U of APCC, 6000 U of PC, 61 dose of CP, 50,000 IU of FVIII. Immunosuppressive therapy (prednisolone 1-1.5 mg/kg/day) was started on day 67 and lasted for 12 months. Bleeding stopped completely 10 months after delivery, and after 14 months the inhibitor was not detected, factor levels and APTT returned to normal. Scheduled reconstructive surgery on the urinary tract was performed without the use of transfusion replacement therapy.&#x0D; Conclusions. Recurrent postpartum hemorrhage requires early diagnosis of coagulation factors inhibitors, which will ensure specific transfusion and immunosuppressive therapy, avoidance of serious consequences, including extirpation of the uterus and reduce the economic costs of treatment.

Coating strategies for expansion of mesenchymal stromal cells in a hollow-fibre bioreactor

Background & Aim Background The increasing request for culture expanded mesenchymal stromal cells (MSC) in the last years discloses the need to reduce costs and man power in the manufacturing process. This can be achieved by the use of closed, (semi-)automated bioreactor systems. We have decided to test a functionally closed hollow-fibre bioreactor system (Quantum®). Surveillance of metabolic parameters and adaptation of feeding in dependence of these is possible. However, the nature of the hollow-fibre surface does not support attachment of MSC without coating. Several biological substances for coating are available, either as isolated proteins (e.g. fibronectin, vitronectin), or as complex protein mixtures derived from human blood (e.g. cryoprecipitate, platelet lysate). The use of such closed systems additionally reduces the risk of contaminations. Methods, Results & Conclusion Methods MSC were cultured as conventional cell culture or in a platelet lysate (PL), cryoprecipitate (CP), vitronectin (VN), or fibronectin (FN) coated Quantum® bioreactor (TerumoBCT) for 5 - 15 days in alphaMEM (Lonza), supplemented with 5% - 10% platelet lysate (PL from IKT Ulm) and 1 i.u. heparin (B.Braun). The surface of the Quantum® bioreactor is 21,000 cm2. For Quantum®, the feed rate was adjusted based on daily measured lactate or glucose levels. For conventional cell culture, mainly 2 chamber CellSTACK® (Corning) with a surface of 1272 cm2 were used and complete medium exchange was performed twice a week. TrypZEAN® (Lonza) was used for detachment of cells. Results For results of the cell expansion experiments (N ≥ 3) using the different coating reagents refer to Table 1. Conclusion We showed that the Quantum® bioreactor is suitable for expansion of MSC using PL, CP, FN or VN as coating reagent. Despite higher doubling times for cells grown in the Quantum®, this system may help to save costs since less man power is needed to manage the system and several steps do not necessarily have to be performed in a class A cabinet. In addition, clinically relevant cell numbers could be achieved by the use of a single bioreactor (data not shown). Perspective Protocols for cell expansion in the Quantum® still may have to be optimized in order to increase its potential in saving man power and consumables.

Analysis of the hemostatic therapy in liver transplantation guided by rotational thromboelastometry or conventional laboratory tests.

Coagulopathy is quite common in chronic liver disease patients undergoing orthotopic liver transplantation (OLT). Diagnosis of intraoperative bleeding disorders is based on conventional laboratory tests (CLTs), and thus, the patients are frequently exposed to unnecessary transfusions of blood products. The present study aimed to analyze the intraoperative administration of blood products in patients undergoing OLT, using rotational thromboelastometry (ROTEM) or CLTs. A cohort comprising 153 patients undergoing OLT, of whom 82 were evaluated with ROTEM and 71 by CLTs. Both groups were analyzed intraoperatively: the transfusion of blood products. The incidence of patients transfused with cryoprecipitate (CRYO) and/or fibrinogen concentrate (54.9 vs. 19.7%; P < 0.001) and prothrombin complex concentrate (PCC) (32.9 vs. 9.9%; P = 0.008) increased significantly in the ROTEM group than in CLT group, respectively. The amount of transfused patient with CRYO (7.6 vs. 1.2; P < 0.001), fibrinogen concentrate (0.8 vs. 0.2; P = 0.004) and PCC (1.4 vs. 0.2; P = 0.002) increased significantly in the ROTEM group than in the CLT group, respectively. In the analysis of fresh-frozen plasma (FFP), the incidence of transfused patients was significantly higher in the CLT group than in the ROTEM group (46.5 vs. 30.5%; P = 0.047, respectively), with a moderate correlation with red blood cells transfusion (r = 0.67, P < 0.001). The incidence of patients receiving antifibrinolytics was significantly higher in the CLT group than in the ROTEM group (85.9 vs. 47.6%; P < 0.001, respectively). Transfusion protocol-based thromboelastometry was able to guide administration of hemostatic factors and reduced administration of FFP and antifibrinolytics.

Evaluation of the efficacy of autologous cryoprecipitate for attaching conjunctival autograft after primary pterygium excision

Purpose The aim of this study was to evaluate the long-term safety and efficacy of using autologous cryoprecipitate for attaching conjunctival autograft and to compare the results of such technique with the use of vicryl sutures in patients undergoing primary pterygium excision, in terms of surgical time, postoperative patient comfort, visual acuity, complications, and recurrence rate. Patients and methods This is a prospective, interventional, comparative clinical study. It included 200 patients with primary nasal pterygium for whom surgical excision of the pterygium with conjunctival autograft obtained from the same eye was performed. The patients were divided into two groups: autologous cryoprecipitate was used in 100 patients (glue group) and absorbable sutures (8/0 vicryl sutures) were used in 100 patients (suture group) to attach the free conjunctival graft. The main outcome measures included operative time, postoperative pain, lacrimation, foreign body sensation, recurrence rate, and complications. The follow-up period was 24 months. Results The mean operative time was 20.28±2.73 min in the glue group and 31.04±6.52 min in the suture group, with a statistically significant difference (P Conclusion Using autologous cryoprecipitate for attaching conjunctival autograft in primary pterygium surgery resulted in shorter operative time and less postoperative pain, foreign body sensation, lacrimation, and subconjunctival hemorrhage. In addition, it decreased the recurrence rate. The cryoprecipitate method appeared to be effective, reliable, and safe after long-term follow-up.