Fresh Frozen Plasma Requirements Research Articles

The Impact of Intra-Operative Heparin on Thromboembolism and Death in a Matched Cohort of Patients with a Ruptured Abdominal Aortic Aneurysm

Portuguese nationwide estimates indicate that 20% of abdominal aortic aneurysms (AAAs) are treated when ruptured. In these cases, intra-operative unfractionated heparin (UFH) usage rates vary widely. Evidence on this topic is scarce and focused on patients treated by open repair (OSR). The aim was to determine the influence of UFH on peri-operative thromboembolic events (TEs) and death in a cohort of ruptured AAA (rAAA). Retrospective, single-centre, comparative study. From 2011 to April 2023, all consecutive rAAAs (endovascular repair [EVAR] and OSR) were considered. Primary outcomes were 30-day TE free survival and TE rates. The secondary outcome was 30-day death. Safety endpoints were procedural blood loss, blood product requirements, and secondary interventions due to haemorrhage. Using propensity score matching (PSM) each UFH patient was matched with one no UFH patient in a 1:1 ratio. The study included 250 patients. After PSM, 190 patients were analysed (EVAR: 60.0% no-UFH vs. 64.4% UFH). TE free survival estimates favoured the UFH group (67.3% vs. 47.2%, p = .009; UFH adjusted odds ratio [aOR] 2.01, 95% confidence interval [CI] 1.04-4.17). TEs were more frequent in the no UFH group (20.0% vs. 44.2% patients, p < .001; UFH aOR 0.31, 95% CI 0.15-0.65 for any TE), driven by an increase in bowel ischaemia (17.9% no UFH vs. 3.2% UFH, p = .001). Most events occurred in the first 72 hours. EVAR was associated with reduced TE and improved TE free survival (aOR 0.20, 95% CI 0.09-0.45 and aOR 5.54, 95% CI 2.34-13.08, respectively). No significant differences in 30-day survival were noted (75% no-UFH vs. 83% UFH, p = .26; aOR 1.08, 95% CI 0.48-2.43) nor in blood loss, peri-operative red blood cell and fresh frozen plasma requirements, or secondary interventions due to haemorrhage (p = .10; p = .11; p = .13 and p = .18 respectively). In this cohort, intra-operative UFH was safe and associated with improved TE free survival, driven by a reduction in bowel ischaemia. Conversely, mortality remained unaffected. Randomised controlled trials are required to confirm these findings.

Bakri balonun 12 saatten daha uzun süre uygulanması postpartum uterus atonisi tedavisinde olumlu klinik sonuçlar sağlar mı?

Aim: If the initial treatment techniques fail, intrauterine balloon tamponade (IUBT) devices such as Bakri balloon tamponade (BBT) is an effective treatment for reducing the bleeding in uterine atony patients. However, the duration of the Bakri balloon varies widely in clinical practice, and there is no consensus in this issue. This study aimed to compare the clinical outcomes of the Bakri balloon removed in less or more than 12 hours in patients with severe postpartum haemorrhage (PPH).&#x0D; Materials and methods: This retrospective study included 108 patients who underwent Bakri balloon for severe PPH after vaginal delivery. Patients were divided into two groups as the duration of Bakri balloon 8-12 hours (Group I) and &gt;12 hours (Group II). BBT was considered to be successful if the bleeding was stopped, and the patient did not require additional invasive procedures. Age, parity, gestational week, cause of bleeding, presence of co-morbidity that may increase bleeding (multiple gestation, magnesium sulphate infusion), estimated blood loss (EBL) before and after Bakri balloon, postpartum infection, erythrocyte and fresh frozen plasma requirement and invasive procedure requirement of the groups were compared.&#x0D; Results: In group I, 26 patients (52%) underwent erythrocyte transfusion, and 18 patients (36%) underwent both erythrocyte and fresh frozen plasma (FFP) transfusion. In group II, 28 patients (41.2%) underwent erythrocyte transfusion, and 21 patients (30.9%) underwent both erythrocyte and FFP transfusion. These differences were not statistically significant (p=0.42 and p=0.21, respectively). Bacri balloon was failed to reduce bleeding in one patient (2%) in group I and one patient (1.5%) in group II, and these patients had to undergo invasive surgical procedures (hysterectomy). There was no statistically significant difference between the groups in terms of failed to reduce bleeding rates (p=0.52).&#x0D; Conclusion: Keeping the Bakri balloon in place for longer than 12 hours does not provide favourable clinical outcomes compared to keeping in place for less than 12 hours.

Antifibrinolytic agents for paediatric scoliosis surgery: a systematic review and meta-analysis.

Systematic review and meta-analysis of randomised controlled trials. The purpose of this study is to perform a systematic review and meta-analysis of antifibrinolytic agents for paediatric spine surgery. Bleeding is an important consideration in paediatric scoliosis surgery; blood loss leads directly to higher morbidity and mortality. Antifibrinolytics are an attractive non-invasive method of reducing bleeding as evidenced in arthroplasty, cardiac surgery and adult scoliosis surgery. A thorough database search of Medline, PubMed, EMBASE and Cochrane was performed according to PRISMA guidelines, and a systematic review was performed. Five randomised controlled trials were identified in this meta-analysis, consisting of a total of 285 spine surgery patients with subgroups of tranexamic acid (n = 101), epsilon aminocaproic acid (n = 61) and control (n = 123). This meta-analysis found that antifibrinolytics lead to statistically significant reductions in peri-operative blood loss (MD - 379.16, 95% CI [- 579.76, - 178.57], p < 0.001), intra-operative blood loss (MD - 516.42, 95% CI [- 1055.58, 22.74], p < 0.001), reduced fresh frozen plasma requirements (MD - 307.77, 95% CI [- 369.66, - 245.88], p < 0.001) and reduced post-operative blood loss (MD - 185.95, 95% CI [- 336.04, - 35.87], p = 0.02). This meta-analysis concludes that antifibrinolytics lead to statistically significant reductions in peri-operative blood loss, intra-operative blood loss, reduced fresh frozen plasma requirements and reduced post-operative blood loss with TXA. These slides can be retrieved under Electronic Supplementary Material.

Retrograde autologous priming in surgery of thoracic aortic aneurysm.

Surgery of thoracic aortic aneurysm (TAA) is associated with blood loss and coagulopathy and a high need for red blood cell (RBC) volume. Retrograde autologous priming (RAP) decreases haemodilution during cardiopulmonary bypass (CPB). The aim of this study was to show the effect of RAP during surgery of TAA repair on haemodilution, the need for RBC transfusion and the postoperative course compared to conventional CPB (cCPB). A retrospective study was performed on 120 patients with TAA. Half of these patients underwent cCPB and the other half received RAP. Statistical analysis was performed using IBM SPSS statistics 23. The χ2 test, the Fisher's exact tests, the independent t-test and the Mann-Whitney U-test were used. Statistical significance was assumed at P-value <0.05. Lower blood product requirements were observed for the RAP group regarding the transfusion of intraoperative RBC (0.87 ± 1.33 vs 1.97 ± 2.43, P = 0.013), postoperative RBC (0.57 ± 1.4 vs 1.32 ± 1.82, P = 0.002) and postoperative fresh frozen plasma (0.52 ± 1.63 vs 1.48 ± 3.32, P = 0.036). The postoperative drainage loss showed significantly lower measurements for the RAP group after 6 h (295.9 ± 342.6 vs 490.6 ± 414.4 ml, P ≤ 0.001), 12 h (450.1 ± 415.5 vs 652.1 ± 463.9 ml, P < 0.001) and 24 h (693.1 ± 483.9 vs 866.4 ± 508.4 ml, P = 0.004). RAP is a safe and easy method to reduce RBC transfusion in TAA surgery without any adverse effects on the clinical outcome. We were also able to show beneficial effects on fresh frozen plasma requirements and postoperative chest drainage volume. Furthermore, improved microcirculation can be suspected. In consequence, we have implemented RAP as a clinical standard during thoracic aortic surgery.

The quality changes in fresh frozen plasma of the blood donors at high altitude.

ObjectiveAccording to the international guidelines, fresh frozen plasma (FFP) is unanimously used to treat coagulation disorders. The quality of FFP is critical for the clinical transfusion. Till now, few studies have integratedly evaluated the differences of FFP from blood donors at between high altitude (HA) and low altitude (LA). Besides, there were no special quality standards for HA FFP in China.Materials and methodsUp to 41 HA (Lhasa, 3700 m) and 46 LA (Chengdu, 500 m) blood donors were included in our study to estimate the differences of FFP from HA and LA blood donors. The concentration of total plasma proteins, prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time (TT), fibrinogen (Fbg), factor (F) II, FV, FVII, FVIII, FIX, FX, FXI, FXII, D-dimer, protein C (PC), protein S (PS), antithrombin III (ATIII) and von Willebrand factor antigen (vWF:Ag) were determined, respectively.ResultsAs compared with FFP of LA blood donors, the total protein content of HA blood donors showed a significant decrease (65.2±8.9 vs.57.2±6.3 g/L; p<0.001); PT, aPTT, TT were significantly increased (p<0.001); the levels of FII, FV, FVII, FVIII, FIX, FX, FXI, FXII and vWF:Ag were notably decreased (all p<0.05), whereas Fbg and D-dimer were dramaticly increased (p = 0.038). Additionly, in HA blood donors, vWF: Ag and FVIII:C of O-group was significantly lower (p<0.05) than that of non-O-group. It should be noted that FVIII:C of HA blood donors (0.64±0.10 IU/mL) was lower than the current Chinese quality requirements for FFP (≥ 0.7 IU/ml). No significant differences were observed in PC, PS and ATIII.ConclusionIn general, our findings showed that the quality of FFP was significantly different between HA and LA blood donors, and the current Chinese quality requirements of FFP are not suitable for HA FFP. Therefore, setting up a special quality requirement for HA is quite necessary and meaningful.

Comparison of Different Dosing Protocols of Anti-Snake Venom (ASV) in Snake Bite Cases.

Considering the cost of Anti-Snake Venom (ASV) and irregularity in its supply, there is often a need to curtail doses of ASV, despite guidelines for management of snake bite. During June 2013 to September 2013, when ASV was in short supply, our institutional committee reviewed the overall hospital statistics of snake bite cases as well as scientific literature and formulated a working modified protocol that used low dose of ASV in snake bite cases. To retrospectively analyse and compare the modified ASV protocol versus conventional ASV protocol with respect to outcome, number of ASV vials required, duration of stay in the hospital/ ICU, and additional supportive interventions needed. This was a retrospective study conducted at a tertiary care teaching hospital, Maharashtra, India. Hospital records of inpatients admitted for snake bite during June 2013 to September 2013 (since introduction of the modified protocol) as well as during June 2012 to September 2012, (when patients received conventional protocol-historical controls) were retrospectively analysed to assess the number of ASV vials received by the patients during the stay, need for supportive therapy, duration of stay and outcome of the patients. There was a significant reduction in average number of ASV vials per patient, required vide the modified protocol compared to their historical controls (10.74±0.95 vs 28.17±2.75 p<0.001). There was no significant difference in outcome, need for dialysis, fresh frozen plasma requirement, need for ICU stay and duration of hospitalization of snake bite patients. Yet, the average cost of management of each patient reduced by approximately 11974.41 INR per treated patient, based on the requirement of ASV. The modified ASV protocol used in this study is more cost effective as compared to the conventional protocol, deserves prospective evaluation and may be followed at least during prime time of scarcity of ASV.

Assessment of thrombin generation using thromboelastometry in cirrhotic patients with hepatocellular carcinoma undergoing liver transplantation

Due to the mixed etiology of liver disease, cirrhotic patients with hepatocellular carcinoma may have either a pro-thrombotic or a bleeding tendency. Haemostatic assessment and blood management represent key issues during liver transplantation (LT) having a significant impact on survival and postoperative outcome. Our aim was to assess haemostatic profile in liver transplant recipients with hepatocellular carcinoma (HCC) and to evaluate its impact on perioperative anaesthetic management. We prospectively included 122 patients that underwent liver transplantation between January and December 2013. Exclusion criteria were incomplete data recall, preoperative anticoagulation treatment, acute liver failure and emergency re-transplantation. Coagulation was assessed using standard coagulation tests and rotational thromboelastometry (ROTEM®) assay performed preoperative and 15 minutes after reperfusion of the liver. We recorded introperative blood loss, transfusion requirements, Post Anaesthesia Care Unit length of stay and incidence of postoperative renal, pulmonary, thrombotic and hemorrhagic complications. After we applied the exclusion criteria, 80 patients were included in the final analysis: 24 patients in the HCC groupand 56 in the non-HCC group. Patients with HCC had increased preoperative thrombin generation demonstrated by a shorter clot formation time (142 vs. 381 sec, p= 0.01, 95% CI[41.9, 292.4] ) and a shorter time to maximum velocity of clot formation (153 vs. 209, p=0.027, 95% CI [6.59, 105.3] ). Intraoperative findings showed no differences in blood loss between the two groups, but lower fresh frozen plasma requirements (11.5 vs. 16.6 units, p =0.031) was observed in the HCC group. Intraoperative ROTEM® variables were similar in both groups measured after reperfusion of the graft. No statistically significant differences in postoperative outcome were observed between groups. In conclusion, patients in HCC group have increased preoperative thrombin generation as demonstrated by ROTEM derived parameters. During major abdominal surgery, like LT, and increased blood loss thrombin generation is similar in patients with and without HCC, demonstrating that haemostatic reserve is limited in HCC group.

Protocol for splenic salvage procedures in this era of non-operative management.

The increased prevalence of non-operative management of splenic injuries contributes to the infrequent use of salvage procedures. Nevertheless, salvage procedures are sometimes required. The study aimed to evaluate the safety and feasibility of our salvage procedure protocol for selected patients. This retrospective study included 27 splenic injury patients divided into two groups: those treated by salvage procedures (splenorrhaphy or partial resection) and those who underwent splenectomy. Our salvage procedure protocol was applied in the following situations: if hemodynamics were stable during laparotomy or bleeding was fully controlled by manual or incisional mobilization of the organ, when no more than two other organs required repair, and if no clinical coagulopathy existed. The splenic abbreviated injury scale, intraoperative bleeding, and transfusion requirements of packed red blood cells and fresh frozen plasma requirements in 24 h were significantly lower in the salvage procedure group. There was no difference in the injury severity score, initial amount of bleeding, length of intensive care unit stay, or morbidity and mortality rates between the groups. Patients who underwent salvage procedures were managed without major complication, except one pseudoaneurysm case. We confirmed the feasibility of our salvage procedure protocol for selected patients, particularly for those with simple or lower grade injuries.

Quantitative evaluation of plasma after methylene blue and white light treatment in four Chinese blood centers

Pathogen reduction technology is an important process in the blood safety system, including solvent/detergent treatment, filtration and methylene blue-photochemical technology (MB-PCT). To investigate the quality of MB-PCT-treated plasma, plasma samples from four Chinese blood centers were analyzed over 12 months of storage to determine the recovery of activities and levels of various plasma proteins. Ten plasma units each from the Suzhou, Yancheng, Chongqing and Shandong blood centers were divided into two aliquots. One was subjected to treatment with one of two methylene blue-photochemical technology instruments and the other was used as control. The treated and untreated sample pairs were stored at -30°C. The recovery rates of coagulation factors, inhibitor proteins, total protein, immunoglobulins, and complement proteins were measured at different time points after storage. The mean recovery of most proteins exceeded 80% after MB treatment. The exceptions were factor XI and fibrinogen, of which only 71.3-74% and 69.0-92.3% were retained during storage. The two equipment types differed in terms of residual MB concentration in the plasma samples (0.18 μM and 0.29 μM, respectively). They had similar protein recovery rates at 0.5 month but differed at later time points. The four blood centers differed significantly with regard to factor II, V, VIII and fibrinogen activities. Only the samples from the Shandong blood center met the methylene blue treated fresh frozen plasma requirement. The major factor that influenced the quality of the MB-FFP samples was the time taken between blood collection and storage. Methylene blue treated plasma showed reduced coagulation factor (CF) activity and protein levels. The MB treatment-induced damage to the proteins was acceptable at the four Chinese blood centers, but the quality of the MB-treated plasma in general was not satisfactory. The main factor affecting plasma quality may be the duration of the collection and processing.

Comparison of Different Doses of ε-Aminocaproic Acid in Children for Tetralogy of Fallot Surgery: Clinical Efficacy and Safety

The purpose of this study was to compare 2 different doses of ε-aminocaproic acid (EACA) and assess their relative efficacy and safety in children undergoing corrective surgery for tetralogy of Fallot (TOF). A prospective, randomized, controlled study. A tertiary care center. One hundred twenty children undergoing corrective surgery for TOF using cardiopulmonary bypass (CPB). Group 1 received 100 mg/kg of EACA after induction, upon initiation of CPB, and after protamine. Group 2 received 75 mg/kg of EACA after induction, followed by a maintenance infusion of 75 mg/kg/h until chest closure, and an additional 75 mg/kg upon initiation of CPB. Group 3 did not receive any antifibrinolytic agent or placebo. Cumulative mean blood loss, total packed red blood cells, and fresh frozen plasma requirements were significantly less in group 2 (p ≤ 0.01). There were no significant differences in the total platelet concentrate transfused, re-exploration rate, incidence of renal failure, arrhythmias, neurologic complications, mortality, or length of intensive care unit stay among the 3 groups. The incidences of perioperative ST/T changes and chest closure time were significantly less in group 1 and group 2 (p ≤ 0.01). The duration of mechanical ventilation was significantly less in group 2 (p ≤ 0.01). EACA was effective in reducing the postoperative blood loss and transfusion requirements in children undergoing corrective cardiac surgery on CPB for TOF. The dose regimen of 75 mg/kg after induction, followed by a maintenance infusion of 75 mg/kg/h until chest closure, and an additional 75 mg/kg upon initiation of CPB were more effective.

Selective microcoil embolization of arterial gastrointestinal bleeding in the acute situation

To evaluate microcoil embolization in the interventional treatment of acute upper and lower gastrointestinal bleeding. Forty-four patients (29 men, 15 women) with active arterial gastrointestinal bleeding were treated with microcoil embolization. The analysis included technical/clinical success, morbidity, mortality, and intervention-related mortality. Age, sex, underlying malignant disease, number of embolizations, preinterventional and postinterventional hemoglobin levels, blood products administered peri-interventionally, amount of embolization material used, duration of fluoroscopy, and use of contrast medium were evaluated for possible effects on technical and clinical success. The primary technical success rate of microcoil embolization for acute gastrointestinal bleeding was 88.6% with a clinical success rate of 56.8%. Minor and major complications occurred in 13.6 and 18.2% of patients, respectively. Intervention-associated mortality, due to intestinal ischemia, accounted for 4.6% of the total 18.2% mortality rate. Patients with technically successful embolization had a statistically significant increase in hemoglobin (P<0.01) after the intervention and a decrease in need for packed red blood cells, (P<0.01), fresh frozen plasma (P<0.01), and coagulation products (P<0.01). A smaller postinterventional fresh frozen plasma requirement was associated with a better clinical outcome (P=0.02). Microcoil embolization of arterial gastrointestinal bleeding in the acute situation has a high-technical success rate. The number of transfusions required before and after the intervention has no significant effect on technical success. Postinterventional fresh frozen plasma demand negatively correlates with clinical success.

The Comparison of the Perioperative Changes in Lactate and Prothrombin Time Between Deceased Versus Living Donor Liver Transplantation

Introduction The present study compared the functional capacity of the grafts by evaluating changes in lactate and PT after reperfusion among deceased donor liver transplantation (DDLT) versus living donor liver transplantation (LDLT). Methods We performed a retrospective analysis of primary adult liver transplantations (45 and 77 recipients in DDLT and LDLT, respectively) between January 2007 and December 2009. Lactate was recorded from 5 minutes after reperfusion of graft (R0) to intensive care unit admission (P0). PT expressed in international normalized ratio (INR) was recorded from R0 to postoperative day (POD) 5. These values were compared between two groups. Results The cold ischemia time (CIT), Child-Turcotte-Pugh score, Model for End-stage Liver Disease score, INR, and graft-to-recipient weight ratio were greater in the recipients of DDLT versus LDLT. Lactate and INR at R0 were similar between the two groups, but, the values showed a faster recovery from 1 hour after reperfusion until P0 for lactate and until POD 5 for INR among DDLT recipients. The fresh frozen plasma requirements during corresponding periods were similar between the two groups. Conclusion The functional capacity of the graft measured by changes in lactate and PT after reperfusion showed faster recovery among DDLT versus LDLT recipients despite poorer graft quality (longer CIT) and the recipients' preoperative medical conditions-higher MELD and CTP scores.

Recombinant factor VIIa for intractable life-threatening bleeding in patients with circulatory assist devices

Dear Editor, Circulatory assist devices require tight anticoagulation therapy and may be complicated by severe bleeding. Despite warnings related to potential lethal thrombotic complications, offlabel use of recombinant factor VIIa (rFVIIa) is increasingly reported for refractory hemorrhage, including after cardiac surgery [1, 2]. However, its use in patients with circulatory assist devices has seldom been reported and its safety remains to be established [3–5]. We reviewed 12 consecutive patients with surgically implanted devices who received rFVIIa as rescue treatment for intractable lifethreatening bleeding between March 2004 and November 2009 (Table 1). According to strict and constringent local consensus guidelines, a systematic cross-check for aggressive correction of hypothermia, acidosis, and coagulation factors with parallel surgical control for bleeding or embolization was obtained before rFVIIa administration in all cases. The median age of patients was 45 years. The rFVIIa was administered in the operating room (3/12), in the intensive care unit (7/12), or both (2/12). Underlying conditions were cardiovascular surgery (11/12, including 4 heart transplantations) and bipulmonary transplantation (1/12). The device was an extracorporal membrane oxygenator (9/12) and a left ventricular assist device (3/12). Median dose of rFVIIa was 95 lg/kg (45–180), administered in one (3/12) or several doses (9/12). In these otherwise terminal patients, the bleeding assessed by the number of ml/kg of packed red blood cells and fresh frozen plasma requirement within 12 h before and after rFVIIa administration was significantly reduced. Six patients (50%) died within 30 days, including 2 (18%) from persistent bleeding. A careful analysis of coagulation and other physiological parameters did not reveal significant difference between responders and non-responders.

Antifibrinolytics in liver surgery

Hyperfibrinolysis, a known complication of liver surgery and orthotopic liver transplantation (OLT), plays a significant role in blood loss. This fact justifies the use of antifibrinolytic drugs during these procedures. Two groups of drug namely lysine analogues [epsilon aminocaproic acid (EACA) and tranexamic acid (TA)] and serine-protease-inhibitors (aprotinin) are frequently used for this purpose. But uniform data or guidelines on the type of antifibrinolytic drugs to be used, their indications and correct dose, is still insufficient. Antifibrinolytics behave like a double-edged sword. On one hand, there are benefits of less transfusion requirements but on the other hand there is potential complication like thromboembolism, which has been reported in several studies. We performed a systematic search in PubMed and Cochrane Library, and we included studies wherein antifibrinolytic drugs (EACA, TA, or aprotinin) were compared with each other or with controls/placebo. We analysed factors like intraoperative red blood cell and fresh frozen plasma requirements, the perioperative incidence of hepatic artery thrombosis, venous thromboembolic events and mortality. Among the three drugs, EACA is least studied. Use of extensively studied drug like aprotinin has been restricted because of its side effects. Haemostatic effect of aprotinin and tranexamic acid has been comparable. However, proper patient selection and individualized treatment for each of them is required. Purpose of this review is to study various clinical trials on antifibrinolytic drugs and address the related issues like benefits claimed and associated potential complications.

Serum lipid profile: a predictor of clinical outcome in dengue infection

To correlate serum lipoproteins levels with dengue severity, clinical outcome (patient survival), bleeding severity, capillary leakage, supportive care requirement and hospital stay duration. Single centre, prospective study. Tertiary care hospital. 50 (1 month-18 years) dengue fever cases and 50 age and sex matched non-febrile controls. Methods: patients were classified (WHO criteria) as dengue fever (DF), dengue haemorrhagic fever (DHF), dengue shock syndrome (DSS). Bleeding score; serum triglyceride, cholesterol, HDL, LDL and VLDL was determined. Statistical analysis was done using Chi-squared test with continuity correction, Unpaired t-test, ANOVA with post hoc test, Binary logistic and multinomial regression. 18 (36%) patients were DF, 19 (38%) DHF and 13 (26%) DSS. Lowest cholesterol, VLDL levels seen in DSS and highest in DF. Mean cholesterol level is significantly lower in expired patients and patients with third spacing. Severe bleeding significantly correlated with cholesterol level and hepatic dysfunction but not with platelet count or coagulopathy. Duration of intravenous fluid requirement and packed cell requirement negatively correlated with HDL and cholesterol levels. Fresh frozen plasma requirement negatively correlated with TG, HDL, VLDL and cholesterol levels. Platelet transfusion requirement and duration of hospital stay did not correlate with lipid levels. Intensive care and ventilator requirement negatively correlated with cholesterol level; inotrope requirement negatively correlated with HDL level. Ventilator requirement correlated negatively with TG levels also. Lipid profile changes accompany dengue infection, some of which may indicate severity and guide therapy.

Blood transfusion requirements and independent predictors of increased transfusion requirements among adult patients on extracorporeal membrane oxygenation – a single centre experience

More adults undergo extracorporeal membrane oxygenation (ECMO) now. They have high transfusion requirements. This study described transfusion requirements of adults during ECMO in a single institution, and determined factors associated with high transfusion requirements. Retrospective analysis was done on the amount of blood products received by adults during ECMO. Predictors of increased average daily transfusion requirements during ECMO and increased ECMO duration (which correlated positively with total transfusion requirements) were determined. Forty-one patients (median age 50 years) underwent 42 ECMO sessions for respiratory failure (16.7%), cardiogenic shock (76.2%) or massive pulmonary embolism (7.1%). They received 569 red blood cells, 852 platelets, 126 fresh-frozen plasma (FFP) and 220 cryoprecipitate in total during median ECMO duration of 5 (1-15) days. On multivariate analysis, average daily red blood cell transfusion increased with nadir haemoglobin (Hb) during ECMO (Hb(nadir)) of < 7.5 g/dl (P < 0.001). Average daily platelet transfusion increased with recent antiplatelet agents (P = 0.015) and maximum Hb decline of > 5.5 g/dl during ECMO (P = 0.011). Average daily platelet transfusion > 3 units was also associated with increased ECMO duration (P = 0.024). Average daily FFP transfusion was increased in patients with hypertension (P = 0.007) and Hb(nadir) < 7.5 g/dl (P = 0.050). Patients with sepsis (P = 0.009) or without surgery (P = 0.009) had increased ECMO duration, which correlated positively with total transfusion requirements during the entire ECMO session. ECMO improved mortality of patients with fulminant myocarditis, respiratory failure and massive pulmonary embolism. Adult ECMO patients with lower Hb(nadir) require more daily red blood cell and FFP. Hypertension increases daily FFP requirements. Recent antiplatelet agents, larger Hb decline and longer ECMO duration increase daily platelet requirements. Patients with sepsis or on ECMO for medical reasons have longer ECMO duration, which is associated with total transfusion requirements. Some of these factors may be identified early to optimize blood product support.

Combined Portal Vein Embolization and Neoadjuvant Chemotherapy As a Treatment Strategy for Resectable Hepatic Colorectal Metastases

The objectives of this study are 1) to determine whether the future liver remnant will grow after portal vein embolization (PVE) in patients with colon cancer on concurrent chemotherapy and 2) to determine whether recovery after extended hepatectomy is improved after PVE. Neoadjuvant chemotherapy followed by hepatic resection is an increasingly used therapeutic strategy for curative treatment for colorectal metastases. However, such chemotherapy may result in steatosis, liver damage, and compromised liver regeneration and recovery. This study aims to determine whether PVE can be used during neoadjuvant therapy to enhance growth of future residual liver and to improve postoperative recovery. From September 1999 to September 2004, 100 patients with colorectal metastases to the liver were subjected to PVE as preparation for extended hepatic resection, 43 of whom were embolized during neoadjuvant chemotherapy. Liver growth was examined by computed tomography volumetric analysis. Clinical outcomes of the 71 patients subsequently resected were compared with 100 consecutive patients subjected to extended resection without PVE (controls). After a median wait of 30 +/- 2 days after PVE, patients on neoadjuvant chemotherapy experienced a median contralateral (nonembolized) liver growth of 22% +/- 3% compared with 26% +/- 3% for those without chemotherapy (P = NS). The number of patients with <5% growth was also similar: 4 of 43 versus 6 of 57 (P = NS). Comparison of patients resected after PVE to a simultaneous cohort of 100 consecutive patients subjected to extended resection without prior PVE demonstrated a lower fresh frozen plasma requirement (P = 0.01), a lower peak bilirubin (P = 0.002), and a shorter length of stay (P = 0.03). Mortality was similar (0% vs. 2%). Liver growth occurs after PVE even when cytotoxic chemotherapy is administered. No major complications occurred with PVE. Patients requiring major hepatic resection should be considered for PVE during neoadjuvant chemotherapy to improve subsequent recovery after resection.

Efficacy and Safety of Antifibrinolytic Drugs in Liver Transplantation: A Systematic Review and Meta-Analysis

Although several randomized controlled trials (RCTs) have shown the efficacy of antifibrinolytic drugs in liver transplantation, their use remains debated due to concern for thromboembolic complications. None of the reported RCTs has shown a higher incidence of these complications in treated patients; however, none of the individual studies has been large enough to elucidate this issue completely. We therefore performed a systematic review and meta-analysis of efficacy and safety endpoints in all published controlled clinical trials on the use of antifibrinolytic drugs in liver transplantation. Studies were included if antifibrinolytic drugs (epsilon-aminocaproic acid, tranexamic acid (TA) or aprotinin) were compared with each other or with controls/placebo. Intraoperative red blood cell and fresh frozen plasma requirements, the perioperative incidence of hepatic artery thrombosis, venous thromboembolic events and mortality were analyzed. We identified 23 studies with a total of 1407 patients which met the inclusion criteria. Aprotinin and TA both reduced transfusion requirements compared with controls. No increased risk for hepatic artery thrombosis, venous thromboembolic events or perioperative mortality was observed for any of the investigated drugs. This systematic review and meta-analysis does not provide evidence for an increased risk of thromboembolic events associated with antifibrinolytic drugs in liver transplantation.

Percutaneous tracheostomy in patients with severe liver disease and a high incidence of refractory coagulopathy: a prospective trial

IntroductionThe purpose of this study was to assess the safety of percutaneous dilational tracheostomy (PDT) performed by experienced operators in critically ill patients with liver disease and coagulopathy.MethodsWe conducted a prospective cohort study in a 10-bed specialist liver intensive care unit of a tertiary university teaching hospital. The study consisted of 60 consecutive patients in need of tracheostomy insertion. Patients were categorized as having refractory coagulopathy if their platelet count was less than or equal to 50 × 109 cells/L or their international normalized ratio (INR) was greater than 1.5 on the day of PDT and for the 72 hours afterward despite clotting support.ResultsTwenty-five patients fulfilled the definition criteria of refractory coagulopathy. There was no significant difference in the number of adverse incidents between groups. Only one patient in the coagulopathy group had a severe bleeding complication, but this did not require open surgical intervention. The rate of clinically relevant early complications in all patients was not higher than expected (n = 7, 12%). Resource utilisation was higher for patients with coagulopathy who received significantly more platelet transfusions over the 3-day period (80 versus 49 units; p = 0.009) and who demonstrated a trend toward increased fresh frozen plasma requirements (p = 0.059). The number of patients requiring platelet transfusion was higher in the coagulopathy group (21/25 versus 20/35; p = 0.029). Hospital survival did not differ between groups.ConclusionPDT is safe and not contraindicated in patients with severe liver disease and refractory coagulopathy.

Transfusion requirements during cadaveric and living donor pediatric liver transplantation

Surgical techniques that have been used during liver transplantation (LT) together with patient's coagulation profile and institutional practices are reported to have an effect on transfusion requirements. The aim of this study is to evaluate the transfusion requirement in both cadaveric (CDLT, n = 22) and living donor (LDLT, n = 24) pediatric LT performed in our institution. Balanced general anesthesia was used for all patients. Transfusion requirements were met to maintain a hemoglobin concentration of 8-10 g/dL, platelet level >50 x 10(3)/mL, prothrombin time <20 s and hemodynamic course with observing heart rate, arterial and central venous blood pressures and hourly urine output. Blood loss was replaced by using whole blood. Both groups' perioperative total blood and fresh-frozen plasma (FFP) volumes transfused, fluid requirements and hemodynamic courses, standard coagulation profile and metabolic variables determined in time periods of operations, patients' preoperative characteristics, operative features and postoperative events were compared. The mean transfusion requirements were 37.1 +/- 33.4 and 74.8 +/- 90.8 mL/kg of whole blood (p = 0.059) and 34.5 +/- 24.9 and 51.5 +/- 59.7 mL/kg of FFP for CDLT and LDLT, respectively (p = 0.519). The mean ages and mean body weights of the CDLT patients were higher than LDLT patients (9.7 +/- 5.3 vs. 6.6 +/- 4.4 yr, p = 0.015 and 32.4 +/- 17.7 vs. 21.0 +/- 14.8 kg, p = 0.032, respectively) while the mean operation time (493 +/- 135 vs. 323 +/- 93 min, p = 0.0001) and PELD score (13.1 +/- 11.2 vs. 20.1 +/- 11.8, p = 0.036) were higher for LDLT. In the entire population, multiple regression analysis showed that age, body weight and operation time have a significant combined effect on blood consumption (r2= 0.29, p = 0.003) meanwhile operation time was found to be an effective single variable (p = 0.002). None of the single or combined variables was found to have a significant effect on FFP consumption (r2= 0.17, p = 0.63) and crystalloid use (r2= 0.19, p = 0.11). Hemodynamic courses of both groups were similar. The incidences of metabolic acidosis and hypothermia during the anhepatic periods were higher in the CDLT group (p < 0.05). However, transfusion requirement in the ICU were higher in LDLT group [6.9 +/- 2.2 (n = 6) vs. 18.6 +/- 19 (n = 11) mL/kg, p < 0.05] after LT. As a result of this study in a pediatric patient population, no statistical significance was found in whole blood transfusion and FFP requirements between CDLT and LDLT. Duration of the operation was the primary factor effecting transfusion volume showing the importance of continued small volume losses during uncomplicated LT in this small sized patient population. Transfusion need for pediatric LT should be individualized for each patient based on the intraoperative conditions including surgical and patient features.