Effective Control Of Bleeding Research Articles

Fibrin patch in a pig model with blunt liver injury under severe hypothermia

BackgroundRapid control of hemorrhage is one of the key aspects in trauma handling. To cope with bleeding, local hemostatic approaches are useful, along with surgical and systemic homostatic therapy. In this experimental study, we investigated the efficacy of a fibrinogen/thrombin containing collagen patch (TachoSil) in a coagulopathic pig model with blunt liver trauma under severe hypothermia. MethodsEighteen anesthetized pigs underwent hemodilution by exchanging 70% of the blood volume with Ringer Lactate solution and hydroxyethyl starch 130/0.4 (1:1). Ten minutes after induction of a grade III blunt liver trauma, the animals randomly received treatment with TachoSil (FT-patch, n = 9) or a collagen patch (Tachotop, control group, n = 9). Blood loss, hemodynamics, and coagulation parameters were observed for 2 h. To confirm the consistency of liver trauma, pathologic examination of the liver tissue was performed. ResultsHypothermia (33.5°C ± 0.5°C) and hemodilution led to severe coagulopathy as measured by thromboelastometry and coagulation parameters. After trauma and patch application, thromboelastometry and coagulation parameters in the control group showed further deterioration compared with the stable parameters in the FT-patch group. The total blood loss was significantly reduced in the FT-patch group (FT-patch: 1195 mL; control group: 2495 mL; P < 0.001). Concordantly, the control animals were hemodynamically jeopardized to a higher degree. Microscopy confirmed a similar degree of liver injury. ConclusionsDespite severe hypothermia and coagulopathy, TachoSil provided effective hemorrhage control in pigs with blunt liver injury. Therefore, TachoSil demonstrated usefulness as an additional early therapy in cases of uncontrolled bleeding following severe trauma.

Case Scenario: Management of Trauma-induced Coagulopathy in a Severe Blunt Trauma Patient

Case Scenario: Management of Trauma-induced Coagulopathy in a Severe Blunt Trauma Patient

Preoperative Superselective Mesenteric Angiography and Methylene Blue Injection for Localization of Obscure Gastrointestinal Bleeding

Localizing obscure gastrointestinal bleeding can be a clinical challenge, despite the availability of various endoscopic, imaging, and visceral angiographic techniques. We reviewed the management of patients presenting with obscure gastrointestinal bleeding during the period from 2005 to 2011. Four patients had preoperative localization of the bleeding site with superselective mesenteric angiography, which was confirmed by the use of intraoperative methylene blue injection. This novel technique allowed us to identify the abnormal pathology, and, consequently, resection of the implicated segment of small bowel was performed without any postoperative complications. Final histology showed that 2 patients had arteriovenous malformations: one had a benign hemangioma of the small bowel, and the other had chronic ischemic ulceration in the ileum. Superselective mesenteric angiography combined with intraoperative localization with methylene blue is an important and innovative technique in the management of patients with unclear sources of gastrointestinal bleeding and allows for effective hemorrhage control with a focused and therefore limited bowel resection.

Prediction score for effective bleeding control using recombinant activated factor VII in perioperative nonhemophilic patients

BackgroundAlthough there has been growing evidence from off-label use of recombinant activated factor VII (rFVIIa) in surgical bleeding, there is limited information on prediction scores. MethodsA retrospective study was conducted from 2004 to 2009. The primary outcome was efficacy of bleeding control. Multivariate logistic regression was performed to develop a new prediction score for success of rFVIIa. ResultsA total of 320 bleeding episodes from 243 nonhemophilic patients who underwent surgery were analyzed. Effective bleeding control was demonstrated in 153 patients. The overall in-hospital mortality rate was 40%. Multivariate analysis identified 4 independent predictors for effective bleeding control: timing of rFVIIa administration, intraoperative blood loss, postoperative international normalization ratio values, and total units of platelets transfused. A rFVIIa success prediction score was developed. ConclusionsThe use of this new prediction score may support decision making by identifying patients with a high probability of obtaining effective bleeding control from rFVIIa therapy.

Effective control of massive venous bleeding by "multioverlapping therapy" using polysaccharide nanosheets in a rabbit inferior vena cava injury model.

To investigate the efficacy of multioverlapping therapy using a polysaccharide nanosheet having 75-nm thickness for sealing and stopping massive venous hemorrhage. The hydrostatic durability of the polysaccharide nanosheet was evaluated invitro when secured to an incised silicon tube. For invivo studies, the inferior vena cava (IVC) of rabbits was cut longitudinally, and multiple polysaccharide nanosheets were overlapped onto the injured IVC. The mechanical hydrostatic durability of the nanosheets was gradually augmented by an increasing number of multilayered nanosheets invitro. This durability was saturated at 80± 6 mm Hg by four layers of nanosheets, which was robust enough to seal injured vessel walls of the large IVC. Multioverlapping therapy using nanosheets effectively sealed and stopped bleeding from the injured IVC invivo. One month later, no inflammatory tissue response was observed around the nanosheet attachment sites of the IVC, while conventional suturing repair in control rabbits showed a severe inflammatory response around the sutured area. The multioverlapping therapy using the polysaccharide nanosheets will effectively stop massive venous bleeding without adverse effects in the immediate or chronic postoperative setting.

Approach to the vascular complications of lumbar disc surgery

The objective of this study was to demonstrate the role of major surgery on patients presenting with vascular complications after lumbar disc surgery. A retrospective analysis of seven cases treated surgically in two tertiary care centers between August 2001 and June 2010 was carried out. The average age of patients (three women and four men) was 35.8 ± 7.2. The most common vessel injured was the left common iliac artery occurring in five patients (71.4%), followed by the left common iliac vein injury detected in two patients (28.5%). Transperitoneal approach was preferred in all cases and primary suturing, graft interposition and end-to-end anastomoses were the surgical methods used for the repair of vascular injury. No mortality was seen in our series during the follow-up period of two years; however, the most noteworthy complication was paraplegia occurring in one patient. Vascular injury occurring at lumbar discus surgery has a considerable potential for morbidity and mortality. A high index of suspicion is necessary for early diagnosis. In hemodynamically instable patients, the transperitoneal approach provides better exposure and more effective control of hemorrhage, while minimal angiography and endovascular intervention should be preserved for hemodynamically stable cases.

The argon beam coagulator: a more effective and expeditious way to address presacral bleeding

Presacral bleeding is a dreaded complication of pelvic surgery. Rapid and effective control of such bleeding is important to avoid potentially life-threatening outcomes. Various methods for controlling presacral bleeding, all with only limited success, have been described in the literature. We report the alternative technique of using the argon beam coagulator (ABC) to control presacral bleeding. We demonstrate its efficacious use in both open surgery and a laparoscopic case. Our approach involved applying an argon beam at bone setting directly to the bleeders and using a "point and shoot" technique. We found that ABC is a simpler, equally effective and expeditious way of addressing presacral bleeding. To the best of our knowledge, there has been only one previously reported case in the literature of the use of ABC to control presacral bleeding.

Unifying the mechanism of recombinant FVIIa action: dose dependence is regulated differently by tissue factor and phospholipids

Recombinant factor VIIa (rFVIIa) is used for treatment of hemophilia patients with inhibitors, as well for off-label treatment of severe bleeding in trauma and surgery. Effective bleeding control requires supraphysiological doses of rFVIIa, posing both high expense and uncertain thrombotic risk. Two major competing theories offer different explanations for the supraphysiological rFVIIa dosing requirement: (1) the need to overcome competition between FVIIa and FVII zymogen for tissue factor (TF) binding, and (2) a high-dose-requiring phospholipid-related pathway of FVIIa action. In the present study, we found experimental conditions in which both mechanisms contribute simultaneously and independently to rFVIIa-driven thrombin generation in FVII-deficient human plasma. From mathematical simulations of our model of FX activation, which were confirmed by thrombin-generation experiments, we conclude that the action of rFVIIa at pharmacologic doses is dominated by the TF-dependent pathway with a minor contribution from a phospholipid-dependent mechanism. We established a dose-response curve for rFVIIa that is useful to explain dosing strategies. In the present study, we present a pathway to reconcile the 2 major mechanisms of rFVIIa action, a necessary step to understanding future dose optimization and evaluation of new rFVIIa analogs currently under development.

Mise en condition de survie des blessés en opération extérieure : procédure et expérience à partir du terrain afghan

Recent conflicts have led the French Army Health Service to specify the setting condition for the survival of combat casualties in overseas operations. The majority of them are victims of explosion injuries, and an early and effective control of bleeding is the primary means of improving survival. A procedure called "Combat Rescue" is taught. This chronological procedure favours external haemostasis and led to specific equipment, in particular a tourniquet and a haemostatic bandage of high efficiency. It is applied in recent years on the Afghan out-of-hospital theatre. A very front medical presence, which is systematic during evacuations, is a feature of the French Army Health Service operations support.

Usefulness of the Pinch-Burn-Cut (PBC) technique for recipient hepatectomy in liver transplantation.

Backgrounds/AimsSurgical bleeding during recipient hepatectomy is a major concern in liver transplantation (LT). Effective intraoperative control of bleeding is necessary. In the Pinch-Burn-Cut (PBC) technique, a small amount of tissue around the dissection plane is pinched with forceps, electocauterized and gently cut. The present study sought to estimate the usefulness of the PBC technique in LT.MethodsBetween June 2007 and December 2010, 123 adult cases underwent LT in our center. Of these, 72 involved a recipient hepatectomy using the PBC technique (PBC group). and 51 involved the conventional technique (non-PBC group). Clinical parameters were compared between two groups.ResultsThe amount of blood loss and related transfusions were significantly reduced, and the operating time was shorter in the PBC group than in the non-PBC group (p=0.006, p<0.05 and p=0.002, respectively). There was also shorter duration of mechanical ventilation after LT in the PBC group (p=0.017). The incidence of postoperative hemorrhage was lower in the PBC group than in the non-PBC group, but had no statistical significance between two group (19.6% vs. 8.3%, p=0.101).ConclusionsOur data suggest that the PBC technique is effective for bleeding control during recipient hepatectomy in LT.

Peri-Operative Treatment of Giant Nodular Goiter

Objective: To summarize the experience in the peri-operative treatment of giant nodular goiter.Methods: A total of 123 patients with giant nodular goiter sized 6~20 cm were admitted into our hospital from 1990 to 2011 and the clinical data were retrospectively analyzed. These patients underwent total or subtotal thyroidectomy.Results: All patients underwent surgical intervention. Unilateral subtotal thyroidectomy was performed in 40 patients, unilateral total thyroidectomy in 1 patient, bilateral subtotal thyroidectomy in 79 patients, and unilateral total thyroidectomy, removal of entire isthmus and contralateral subtotal thyroidectomy in 3 patients. Nodular goiter was pathologically proven post-operatively. No short-term complications such as dyspnea or thyroid storm were found postoperatively. Post-operative follow up was done for 9 months to 6 years and no recurrence was observed.Conclusion: Comprehensive pre-operative preparation, pre-operative evaluation, complete exposure of the operative field, meticulous operation, effective control and prevention of hemorrhage and prevention against damage to superior and recurrent laryngeal nerves are crucial for the successful surgical intervention of giant nodular goiter.

The role of arterial embolization in controlling pelvic fracture haemorrhage: A systematic review of the literature

To evaluate the efficacy of emergency transcatheter arterial embolization (TAE) in controlling retroperitoneal arterial haemorrhage associated with unstable pelvic fractures. A systematic review of the English literature yielded 21 eligible studies published from 1979 to 2010. Evaluation of clinical and methodological heterogeneity was based on recording certain descriptive characteristics in the component studies. Statistical heterogeneity was detected using Cochran chi-square and I square tests and, when absent, a pooled estimate of effect size for each outcome of interest was calculated. The principal outcomes of interest were efficacy rate of TAE to control intrapelvic bleeding, mortality rates and frequency of associated complications. All component studies were assigned a low to moderate quality score. Methodological and clinical heterogeneity was evident across component studies, but not strongly associated with the observed results. The efficacy rate of TAE ranged from 81 to 100%, while the frequency of repeat TAE for effective control of haemorrhage was 10% (95% CI: 7-13%, range: 0-19%). TAE was associated with an overall mortality ranging from 7 to 47%, and a 0-25% mortality due to intrapelvic bleeding (pooled estimate of effect size: 6%, 95% CI: 4-8%). A very low rate of associated complications were recorded in the component studies (pooled estimate of effect size: 1.1%, 95% CI: 0.1-2.1%). TAE is an efficient acute intervention for controlling severe arterial bleeding related to pelvic trauma with a low complication rate. Repeat of the procedure is occasionally necessary before the effective haemorrhage control.

Recurrent Hemoptysis: An Emerging Life-Threatening Complication in Idiopathic Pulmonary Arterial Hypertension

Hemoptysis is a rarely reported complication of idiopathic pulmonary arterial hypertension (IPAH). We present the case of a 27-year-old woman with IPAH, who suffered from recurrent hemoptysis and who was treated with sitaxsentan and treprostinil and remained stable in World Health Organization functional class II. During several episodes of active hemoptysis, the patient underwent bronchial artery embolization (BAE), always with good immediate results. She developed severe respiratory insufficiency and died of electromechanical dissociation 2 days after another episode, despite effective bleeding control. Recurrent hemoptysis in patients with IPAH emerges as a potential indication for urgent placement on the lung transplant list, independent from the classic prognostic factors of functional class and indices of right-sided ventricular function. Repeated BAE should not be considered as a definitive treatment in patients with pulmonary arterial hypertension with recurrent bleeding, although it may help in bridging patients to lung transplant.

Hemoptysis – etiology, evaluation and treatment in a university hospital

ObjectiveEvaluate patients admitted for hemoptysis, its etiology, use of diagnostic tests, treatment and outcome. Material and methodsA retrospective analysis was done, checking clinical files of patients admitted for hemoptysis, between 1st January 2004 and 31st December 2008. ResultsTwo hundred and thirty seven patients were included in this study, with a mean age of 57.9 years. In patients under 18 years, the most frequent diagnoses were bronchiectasis and congenital cardiopathy. In adults, pulmonary tuberculosis sequelae and bronchiectasis were the dominant diagnoses (22.2 % and 15.8 %, respectively), followed by lung cancer. Active infection was responsible for bleeding in 51 patients, especially pulmonary tuberculosis, pneumonia and tracheobronchitis. The etiology of hemoptysis was not established in 6.3 %. All patients performed chest X-Ray. Chest CT was performed in 81.4 % of patients and fiberoptic bronchoscopy in 52.7 %, the latter locating the source of bleeding in 38.4 % and establishing a final diagnosis in 17.6 %. In most patients, effective control of bleeding was achieved by medical treatment (90.7 %). During these 5 years, arterial embolization was performed in 11.8 % of patients. The main reason for embolization was recurrence prevention. There were 14 deaths (5.9 %), being identified as poor prognostic factors, hemodynamic instability and malignancy. ConclusionsHemoptysis is still a frequent symptom, being chronic infection sequelae and lung cancer their main causes. In this study, factors associated with a worse prognosis were hemodynamic instability and malignancy.

Hemoptises-etiologia, avaliação e tratamento num hospital universitário

Objective Evaluate patients admitted for hemoptysis, its etiology, use of diagnostic tests, treatment and outcome. Methods A retrospective analysis was done, checking clinical files of patients admitted for hemoptysis, between 1 st January 2004 and 31 st December 2008. Results Two hundred and thirty seven patients were included in this study, with a mean age of 57.9 years. In patients under 18 years, the most frequent diagnoses were Bronchiectasis and Congenital Cardiopathy. In adults, Pulmonary Tuberculosis Sequelae and Bronchiectasis were the dominant diagnoses (22.2% and 15.8%, respectively), followed by Lung Cancer. Active infection was responsible for bleeding in 51 patients, especially Pulmonary Tuberculosis, Pneumonia and Tracheobronchitis. The etiology of hemoptysis was not established in 6.3%. All patients performed chest X-Ray. Chest CT was performed in 81.4% of patients and Fiberoptic bronchoscopy in 52.7%, the latter locating the source of bleeding in 38.4% and establishing a final diagnosis in 17.6%. In most patients, effective control of bleeding was achieved by medical treatment (90.7%). During these 5 years, arterial embolization was performed in 11.8% of patients. The main reason for embolization was recurrence prevention. There were 14 deaths (5.9%), being identified as poor prognostic factors, hemodynamic instability and malignancy. Conclusion Hemoptysis is still a frequent symptom, being chronic infection sequelae and lung cancer their main causes. In this study, factors associated with a worse prognosis were hemodynamic instability and malignancy.

Hemostatic effect of a chitosan linear polymer (Celox®) in a severe femoral artery bleeding rat model under hypothermia or warfarin therapy

In this study, the hemostatic efficacy of Celox® in rats under hypothermia or warfarin treatment was investigated. A total of forty-eight Sprague-Dawley female rats weighing 200-350 g were used in the study. Six experimental study groups were designed, as follows: Group 1: Normothermia + compression; Group 2: normothermia + Celox®; Group 3: hypothermia + compression; Group 4: hypothermia + Celox®; Group 5: normothermia + warfarin + compression; and Group 6: normothermia + warfarin + Celox®. Celox® provided effective hemorrhage control in all three tested groups. There was a statistically significant difference between compression and Celox® implementation in all groups in terms of hemostasis (p-values for the normothermia, hypothermia and warfarin groups were p<0.05, p<0.01 and p<0.01, respectively). Furthermore, the compression numbers were significantly lower in all of the groups that received Celox ® than in those in which compression alone was applied (p-values for the normothermia, hypothermia and warfarin groups were p<0.01, p<0.01 and p<0.001, respectively). Celox® provides effective hemorrhage control under conditions of normothermia, hypothermia and use of the oral anticoagulant agent warfarin.

Recombinant Activated Factor VII: Mechanisms of Action and Current Indications

Recombinant activated factor VII (rFVIIa) was initially developed to overcome the limitations of existing treatments for patients with congenital hemophilia and inhibitors. Clinical success in this arena led to experimental use in other coagulopathies characterized by impaired thrombin generation, and approval for use in acquired hemophilia, factor VII deficiency, and Glanzmann's thrombasthenia soon followed. Extensive research and growing experience in the clinical setting has increased our knowledge of rFVIIa and improved our understanding of how its mechanism of action leads to effective bleeding control. This article reviews current understanding of the mechanisms of action of rFVIIa before providing a brief overview of clinical experience to date in its licensed indications. The agent's safety profile is also examined, along with recent advances in rFVIIa dosing and storage that may help to improve both clinical outcomes and patient quality of life.

Radiofrequency ablation for controlling iatrogenic splenic injury

Radiofrequency ablation for controlling iatrogenic splenic injury

Degradable, antibacterial silver exchanged mesoporous silica spheres for hemorrhage control

Effective hemorrhage control becomes increasingly significant in today's military and civilian trauma, and current available local hemostatic agents have been reported to have various drawbacks and side effects. Herein in this study, a silver exchanged calcium doped ordered mesoporous silica sphere (AgCaMSS) with good degradability and antibacterial properties was developed for hemorrhage control. The well-ordered and symmetry hexagonal AgCaMSS with pore size of 3.2 nm, BET surface area of 919 m 2/g and pore volume of 0.74 m 3/g was prepared by one-step based catalyzed self-assembly and subsequent ion-exchange procedures. The degradation behaviors in Tris–HCl solution indicated that the addition of calcium and silver facilitated the dissolution and the weight loss of the prepared AgCaMSS could attain more than 40% after 42 days. The results obtained demonstrated that the optimal AgCaMSS formulation could significantly promote the blood clotting, activate the intrinsic pathway of coagulation cascade, induce platelet adherence. Consequently, effective hemostasis with low exothermic effects was achieved and the mortalities in femoral artery and liver injury models were reduced. The antibacterial experiment using broth culture method revealed that the prepared AgCaMSS had better antibacterial activities against Escherichia coli and Staphylococcus aureus. Based on these results, it can be concluded that the AgCaMSS developed here would be a promising material platform for designing hemostats in more extensive clinical application.

Outcome of Conservative Surgery for Giant Cell Tumor of the Sacrum

Retrospective analysis. To estimate the clinical outcome of conservative surgery (intralesional curettage or partial excision) aided by effective intraoperative hemorrhage control in patients with giant cell tumors of the sacrum. Giant cell tumors of the sacrum present a challenging therapeutic problem. Wide resection is associated with higher morbidity and spinal instability. Whether conservative surgery aided by effective intraoperative hemorrhage control can achieve low recurrence rates remains uncertain. The clinical records of 24 patients with an average age of 35 years who had undergone conservative surgery for sacral giant cell tumor between 1996 and 2005 were evaluated retrospectively. The disease onset, tumor size, operation records, complications, follow-up status, and functional outcome were analyzed. The mean duration of follow-up was 58 months (median, 50 months; range: 25-132 months). All the patients had a conservative procedure aided by intraoperative occlusion of the abdominal aorta. The mean estimated blood loss was 3217 mL. The mean length of the operation was 190 minutes. Seven (29.2%) patients developed recurrences. The mean time from the index surgical procedure to the first recurrence was 13 months (range: 8-31 months). The 5-year local recurrence-free survival rate was 69.6%. Seventeen (70.8%) patients retained normal urinary function and 16 (66.7%) patients preserved normal bowel function. No patients had urinary or bowel dysfunction when both S3 nerves were preserved. Ten (41.7%) patients had complications perioperatively or during the follow-up. Seven (29.2%) patients had wound complications. Considering the acceptable local recurrence rate, conservative surgery aided by effective control of intraoperative hemorrhage should be considered as an alternative procedure for patients with giant cell tumors of the sacrum. The advantages include lower morbidity, reduced neurologic deficits, speed and ease of the surgical procedure, reduced blood loss, preservation of spinal and pelvic continuity, and a low recurrence rate.