Fresh Frozen Plasma Transfusion Research Articles

Predictive factors of mortality in ruptured hepatocellular carcinoma

Introduction: Ruptured hepatocellular carcinoma (HCC) globally carries a high mortality rate. In Thailand, an incidence of ruptured HCC remains high, but data is still lacking. This study aims to identify predictive factors of death in these patients. Method: This is a retrospective study of 45 patients diagnosed with ruptured HCC admitted at Hepato-Pancreato-Biliary and Transplant Surgery Unit, Siriraj Hospital from January 2012 to June 2018. The patients were divided into survived group and mortality group. Demographic data, clinical manifestations, biochemical data, tumor characteristics, and therapeutic procedures were collected and compared. The mortality rate and factors associated with mortality were analyzed. Result: Ten patients and 35 patients were categorized in survived group and mortality group, respectively. Demographic data between two groups were comparable. Emergency hemostasis was achieved with transarterial embolization (TAE) in 40% of survived group and 65% of mortality group. In survived group, hepatectomy could be achieved in 80% of the patients. Univariate analysis showed that low hemoglobin, high creatinine, Child-Turcotte-Pugh B and C, blood and fresh frozen plasma transfusion, inability to undergo definitive hepatectomy, high grade complications (Clavein-Dindo C and D) and liver failure were associated with higher risk of mortality. In the multivariate analyses, significant predictive factors were inability to undergo further definitive hepatectomy (HR: 15.5, 95%CI: 2.0-123.7, p = 0.01) and high serum creatinine (HR: 2.4, 95%CI: 1.0-5.6, p = 0.04). Overall survival of ruptured HCC patients at 1-month, 1-year, and 3-year were 76.0%, 26.4%, 13.2%, respectively. Overall survival after hepatectomy at 1-month, 1-year, and 3-year were 100%, 100% and 75%, respectively. Conclusion: The predictive factors of death in ruptured HCC patients were inability to undergo further definitive hepatectomy and high serum creatinine level. Patients underwent hepatectomy as a definitive treatment could achieve better survival outcome after ruptured HCC.

Preponderant use of fresh-frozen plasma in children despite weaker evidence

BACKGROUND: Considering the higher use of fresh-frozen plasma (FFP) in our hospital, we desired to determine the pattern, prevalence, and potential complications of its utilization in new-born and children with the primary aim to observe its effect on the conventional coagulation screening (CCS) parameters. SUBJECTS AND METHODS: Patients' demographics, clinical indications, and pre- and posttransfusion CCS parameters such as the prothrombin time, the international normalized ratio (INR), and partial thromboplastin time were observed over a period of 10 months. Any improvement observed in the laboratory parameters after FFP transfusion was noted. RESULTS: We studied 433 episodes, where 499 FFP units were utilized in 184 patients. Mean age in years was 6 ± 0.16 (new-born to 17). Diagnoses-wise majority had diffuse intravascular coagulation with sepsis 25% (46/184) followed by febrile illness 23% (42/184). Around 46% (84/184) patients had bleeding episodes of which four had known family history of bleeding (three factors IX and one factor XI deficiency). Mean doses of FFP utilized (mL/kg) in children and infants were 12.6 ± 6.3 (n = 297 episodes) and 14.4 ± 6.3 (n = 136 episodes), respectively (P = 0.006). Mean change in INR in the cohort with deranged coagulation parameters against the overtly bleeding cohort was 0.85 versus 0.40 (P = 0.006). CONCLUSION: The study elicits minimal evidence in correcting the coagulation parameters, especially in the infants, whenever FFP was transfused prophylactically. Joint-decision making of the pediatricians and transfusion medicine physician would promote judicious use in children.

Critical audit of fresh frozen plasma transfusion practices in obstetric and gynecology departments in a tertiary care hospital – Where and what needs to be improved?

Introduction: Fresh frozen plasma (FFP) prepared from whole blood contains plasma proteins and all the coagulation factors including factor V and factor VIII. Many FFP transfusion guidelines have been published till now. However, the administration is inappropriate without any scientific basis or clinical indication in many hospital settings. Aims and Objectives: A retrospective study was carried out between February 2016 and August 2016 in the regional blood transfusion center of our institution to assess the appropriate usage of FFP in obstetrics and Gynecology. It was done using the FFP transfusion guidelines based on the British Committee for Standards in Hematology and College of American Pathologists. Materials and Methods: Blood bank requisition forms received from patients of obstetrics and gynecology department during this period were screened. Indications for transfusion requests were studied and further divided into appropriate and inappropriate requests. Results: A total of 901 units of FFP were issued to 250 patients during this period. Appropriate usage of FFP was found in 67% and inappropriate usage in 33% of the 250 patients evaluated. Bleeding related to surgery with deranged coagulation profile constituted the most common appropriate indication for FFP infusion, and severe anemia was the most inappropriate indication for FFP use. Conclusion: The usage of FFP requires a proper understanding and knowledge about the appropriate and inappropriate usages. It also involves training and supervising the medical staff at regular intervals. Computerized audit programs are required to do a prospective monitoring of the FFP issue and usage in any clinical setting. Further studies are required on the usage of FFP specifically in obstetric and gynecology patients to improve the utilization of this precious blood product.

Blood Component Therapy

Transfusion medicine has undergone advancements since its initiation in the early 20th century. One of these was the discovery that blood can be divided into individual components and delivered separately. Today, blood transfusions nearly always consist of the ad-ministration of 1 or more components of blood. Whole blood transfusion is now limited to situations involving massive resuscitation (trauma ) The most familiar cellular components include packed red blood cells (PRBC), washed PRBC, leukoreduced PRBC and pooled or aphaeresis platelets. Plasma products such as FFP or cryoprecipitate, ant hemophilic factor (CRYO). The transfusion of red blood cells (RBCs), platelets, fresh-frozen plasma (FFP), and cryoprecipitate has the potential of improving clinical outcomes in perioperative and peripartum settings. These benefits include improved tissue oxygenation and decreased bleeding. However, transfusions are not without risks or costs. With the advent of blood component therapy, each unit of whole blood collected serves the specific needs of several, rather than a single patient.Anwer Khan Modern Medical College Journal Vol. 9, No. 2: Jul 2018, P 142-147

Morbidity and Mortality of Crystalloids Compared to Colloids in Critically Ill Surgical Patients: A Subgroup Analysis of a Randomized Trial.

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: The multicenter randomized Colloids versus Crystalloids for the Resuscitation of the Critically Ill (CRISTAL) trial was designed to test whether colloids altered mortality compared to crystalloids in the resuscitation of intensive care unit patients with hypovolemic shock. This preplanned analysis tested the same hypothesis in the subgroup of surgical patients. The CRISTAL trial prospectively defined patients as critically ill surgical patients whenever they underwent emergency or scheduled surgery immediately before or within 24 h of intensive care unit admission and had hypovolemic shock. The primary outcome measure was death by day 28. Secondary outcome measures included death by day 90, the need for renal replacement therapy, or the need for fresh frozen plasma transfusion. There were 741 critically ill surgical patients, 356 and 385 in the crystalloid and colloid arm, respectively. Median (interquartile range) age was 66 (52 to 76) yr, and 484 (65.3%) patients were male. Surgery was unscheduled in 543 (73.3%) cases. Mortality by day 28 did not significantly differ for crystalloids 84 (23.6%) versus colloids 100 (26%; adjusted odds ratio, 0.86; 95% CI, 0.61 to 1.21; P = 0.768). Death by day 90 (111 [31.2%] vs. 122 [31.7%]; adjusted odds ratio, 0.97; 95% CI, 0.70 to 1.33; P = 0.919) did not significantly differ between groups. Renal replacement therapy was required for 42 (11.8%) patients in the crystalloids arm versus 49 (12.7%) in the colloids arm (P = 0.871). The authors found no survival benefit when comparing crystalloids to colloids in critically ill surgical patients.

The Appropriateness of Fresh Frozen Plasma (FFP) Administration in the Community Teaching Hospital

Objective: Studies demonstrated that inappropriate usage of fresh frozen plasma (FFP) is associated with adverse reaction and poor health outcome in the hospitalized patients. Reducing inappropriate FFP administration in the inpatient settings can minimize potential for adverse events, and foster controllable cost expenditure. Guideline regarding indication of FFP transfusion is scarce. We aimed to assess the appropriateness of FFP transfusion in the setting of community teaching hospital.Methods: A retrospective chart review of patients received FFP transfusion in two community teaching hospitals between 2016-2017 were included in our study. Frequency of appropriateness of FFP transfusion was reported. We also reported percent increase from previous years to compare the FFP usage from 2010-2011 to 2016-2017.Results: Of 138 patients received FFP transfusion in 2016-2017, 62% (86 patients) received inappropriate transfusion. 18% of patients received FFP to correct high INR (>1.6) requiring emergency surgery. 53% of the patients received inappropriate transfusion for bleeding in 2016-2017 compared to 25% in 2010-2011. There was 10% rise of inappropriate or overuse of FFP transfusion in 2016-2017 than 2010-2011.Conclusion: Inappropriate FFP transfusion is significantly associated with adverse health outcome and increased healthcare cost. This study justifies the need for continuous audit for appropriate use of FFP. DisclosuresNo relevant conflicts of interest to declare.

Coagulation and Fibrinolysis Imbalance Demonstrated By Novel Simultaneous Thrombin and Plasmin Generation Assay during L-Asparaginase Treatment Phase of Induction Therapy in Pediatric Acute Lymphoblastic Leukemia

Introduction: L-asparaginase (L-Asp) is one of the risk factor of thromboembolism during ALL chemotherapy. Although the pathogenesis has been still unclarified, L-Asp may have profound effects on hepatic synthesis of pro-, anti-coagulant and fibrinolytic factors. In addition, recent studies demonstrated that the age of over 10-years might be a risk factor for this L-Asp associated coagulopathy. In this study, we hypothesized that change of balance between coagulation and fibrinolysis contributes to hyper-coagulation condition during chemotherapy including L-Asp. In order to clarify our hypothesis, we investigated the global coagulation and fibrinolytic function during the ALL induction therapy with simultaneous thrombin and plasmin generation assay (T/P-GA). Patients: Seventy-two pediatric patients aged 1.0 to 15.2 years (43 males and 29 females) with newly diagnosed ALL were enrolled from Aug. 2014 to Mar. 2018 at four hospitals in Japan. All patients and their families had no thrombotic predisposition. Fifty-five cases (76.4%) (BCP-ALL; n=47, T-ALL; n=7, MPAL; n=1) received BFM-95 oriented protocol consisting of a total of 8 doses of E.coli L-Asp 5,000 U/m2, whilst the others (BCP-ALL; n=13, T-ALL; n=2, MPAL; n=1, Ph-ALL; n=1) received Japan Association of childhood Leukemia Study (JACLS)-ALL02-protcol consisting of a total of 6 doses of E.coli L-Asp 6,000 U/m2. Fifty-two cases (72.2%) were categorized to younger group (1-10 years; median, 4.3 years) and the other cases to older group (>10 years; median, 12.6 years). The percentage of patients of each category were similar in the two treatment protocols (p=0.764). Methods: The global functions of coagulation and fibrinolysis were evaluated using T/P-GA [Matsumoto et al. TH 2013]. This clotting was initiated by the mixture of recombinant human tissue factor (Innovin®, f.c. 1 pM), phospholipid vesicles (f.c. 4 μM) and tissue-type plasminogen activator (f.c. 3.2 nM). Thrombin and plasmin generation were monitored simultaneously using thrombin- and plasmin-specific fluorogenic substrate (Z-Gly-Gly-Arg-AMC and BOC-Glu-Lys-Lys-MAC, respectively) in separate microtiter wells. The first derivatives (velocity) of thrombin and plasmin generation were utilized to derive the parameters, lag time (LT), endogenous potential (EP), peak levels (peak), and time to peak (ttPeak). EP of thrombin generation (T-EP) and plasmin-peak (P-peak) were selected as parameters for evaluation in this study. A ratio of T-EP and P-peak of patients' plasmas to those of control normal plasma were calculated. The conventional laboratory markers of coagulation and fibrinolysis were also monitored by fibrinogen (Fbg), fibrin-Fbg degradation products (FDP), antithrombin (AT), thrombin-AT complex and plasmin-α2 plasmin inhibitor complex. Plasmas were collected at T0; pre-phase of L-Asp, T1; intermittent phase of L-Asp, T2; post-phase of L-Asp, and T3; post induction phase. Results: None of the cases developed L-Asp associated coagulopathy, and two cases (2.8%) developed induction failure. Thirteen cases (18.1%) received fresh frozen plasma transfusion for low Fbg level, whilst 52 (72.2%) cases received AT supplement for low AT level. Fbg showed a median of 165, 99.0, 97.0 and 316 mg/dl at T0, T1, T2 and T3, respectively, and AT showed a median of 143, 80.9, 80.0 and 105%, respectively, whilst the value of other conventional markers remained within reference value. T-EP revealed a median of 1,134, 1,135, 1,221, 1,277 and 1,102 nM, whilst P-peak showed a median of 5.33, 3.75, 3.63, 4.91 and 5.51 nM for T0, T1, T2, T3 and control plasma, respectively, indicating the elevated T-EP ratios and reduced P-peak ratios (Fig. 1). T-EP ratios showed significantly higher at T2 and T3 than at T0 and T1 (p<0.05), whilst P-peak ratios showed significantly lower at T1 and T2 than at T0 and T3 (p<0.01) (median ratios of T-EP/P-peak; T0; 1.06/0.97, T1; 1.04/0.65, T2; 1.12/0.65, T3; 1.17/0.87, respectively). P-peak ratios of the older group showed significantly lower than the younger group at T1 (median; 0.58 vs 0.69, p=0.016). Conclusion: The results from T/P-GA showed that their hemostatic dynamics appear likely to shift to hyper-coagulation and hypo-fibrinolysis at L-Asp treatment phase. These results suggest that the imbalance of coagulation and fibrinolysis might cause thrombotic complication during the L-Asp treatment for ALL, especially in patients aged 10-years older. [Display omitted] DisclosuresNogami:Chugai Pharmaceutical Co., Ltd: Consultancy, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties: Anti-FIXa/X bispecific antibodies , Research Funding, Speakers Bureau.

Utility of prothrombin complex concentrate as first-line treatment modality of coagulopathy in patients undergoing liver transplantation: A propensity score-matched study.

Transfusion management during liver transplantation (LT) is aimed at reducing blood loss and allogeneic transfusion requirements. Although prothrombin complex concentrate (PCC) has been used satisfactorily in various bleeding disorders, studies on its safety, and efficacy during LT are limited. A retrospective chart review of adult patients who underwent living donor LT at a single institute between October 2016 and January 2018 was carried out. The safety and efficacy of PCC in reducing transfusion requirements intraoperatively in patients who received PCC were compared with patients who did not receive PCC. A propensity score-matching technique was used, at a 1:1 ratio, to remove selection bias. After completing the 1:1 propensity score-matched analysis, 60 pairs of patients were identified. The use of PCC was associated with significantly decreased red blood cell transfusion requirements (6.2±4.1 vs 8.23±5.18, P<0.001) and fresh frozen plasma transfusion requirements (2.6±2 vs 6.18±4.1, P<0.001). The number of patients developing postoperative hemorrhagic complications was higher in the non-PCC group. During LT, the use of PCC led to decreased transfusion requirements. No thromboembolic complications related to PCC were noted in this series.

Hyponatremia in Cirrhosis: Implications for Liver Transplantation.

Hyponatremia in cirrhosis is defined as a serum sodium level ≤130 mEq/L and occurs in approximately 22% of patients with cirrhosis. The appearance of hyponatremia in patients with cirrhosis portends a poor prognosis before liver transplantation (LT), independent of the Model for End-Stage Liver Disease (MELD) score. With the development of the MELD-sodium score, the management of hyponatremia has become more relevant than ever before. Overcorrection of hyponatremia before LT or perioperatively can lead to the devastating neurologic condition known as osmotic demyelination syndrome, which is often irreversible and fatal. Therefore, the most important tenet of hyponatremia is to avoid correcting the serum sodium by ≥8 mEq/L in a 24-hour period. Treatment of hyponatremia is highly challenging. The vast majority of patients with cirrhosis have chronic hypervolemic hyponatremia. Fluid restriction increases serum sodium levels, but tolerance and compliance are significant barriers. Diuretic withdrawal is helpful but contributes to worsening fluid overload. There are limited data to support use of intravenous concentrated albumin solutions. The use of the arginine vasopressin antagonists ("vaptans") is contentious; however, they may have a limited role. Risk factors for intraoperative overcorrection of serum sodium include increased utilization of packed red blood cell and fresh frozen plasma transfusions, which are often unavoidable. Intraoperative management is evolving, and more data are needed in regard to the use of sodium-reduced continuous venovenous hemofiltration and the use of trishydroxymethylaminomethane (Tris) to avoid excess sodium rebound. A thorough discussion of the current treatment options before and during LT is given in this review.

The Effect of Fresh Frozen Plasma Transfusion on International Normalized Ratio in Critically Ill Patients

The Effect of Fresh Frozen Plasma Transfusion on International Normalized Ratio in Critically Ill Patients

Management of Major Obstetric Haemorrhage using ROTEM Point-of-Care Haemostasis Analysers Can Reduce Blood Product usage Without Increasing Fibrinogen Replacement Therapy

Major obstetric haemorrhage (MOH) is a leading cause of maternal death and morbidity, with the majority of deaths occurring within four hours of delivery. Therefore, prompt identification of women at risk of MOH is crucial for the rapid assessment and management of blood loss to urgently restore haemodynamic stability. Furthermore, as the rate of blood loss during MOH can increase rapidly in the time when laboratory results are awaited, the management of MOH could benefit from point-of-care coagulation testing by the ROTEM analyser which has a quicker turnaround time compared to standard laboratory coagulation tests. A number of studies indicate that ROTEM-based management of MOH has resulted in a significant reduction in massive transfusions and decreased transfusion of concentrated red cells (CRC) and fresh frozen plasma (FFP) due to a reduction in total blood loss. Several reports which have linked MOH to the depletion of fibrinogen reserves indicate that the reduction in CRC and FFP transfusions is largely due to an increase in early fibrinogen replacement therapy which corrects hypofibrinogenemia. This short report discusses preliminary findings on the impact of ROTEM point-of-care haemostasis analyser on the transfusion of various blood products to obstetric women experiencing MOH at the Royal Gwent Hospital in South wales. The number of blood products transfused following decisions based on the ROTEM analyser measurements (ROTEM group) was compared to historical transfusion data before the ROTEM analyser became available (Pre-ROTEM group). Blood product transfusion in the Pre-ROTEM group was guided by measurements of standard laboratory coagulation tests in conjunction with the established major haemorrhage protocols at the time. The findings indicate that the ROTEM analyser was effective in managing MOH at point-of-care and led to a reduction in the transfusion of CRC, FFP and platelets. However, contrary to published studies, the reduction in blood product usage was not accompanied by an increase in fibrinogen replacement transfusion therapy, suggesting that the ROTEM’s FIBTEM assay accurately quantified fibrinogen levels based on fibrin-clot firmness to enable an early diagnosis of hypofibrinogenemia. Early establishment of the absence of hypofibrinogenemia helped to prevent unnecessary transfusion of fibrinogen concentrate in this study. These findings support the adoption of routine use of ROTEM analysers at point-of-care on labour wards to manage MOH and reduce fibrinogen replacement therapy. The ease of use and rapidity of ROTEM tests could enable departure from globally directed correction of coagulopathy during MOH to a more focussed and precise target transfusion therapy, which will ultimately reduce blood product wastage (including fibrinogen concentrate) whilst minimising transfusion-associated side effects such as alloimmunisation, circulatory overload and dilutional coagulopathy.

FRESH FROZEN PLASMA

Introduction: As the use of Fresh Frozen Plasma (FFP) is having establishedcomplications including Allergic reactions, infectious complications, hemolysis, fluid overload, transfusion related acute lung injury (TRALI) and immune suppression, therefore it mustbe used cautiously. Objectives: To evaluate the inappropriate use of FFPs, to carry out anaudit of appropriateness of FFP transfusion with reference to international guidelines and setfoundations for blood bank and transfusion protocols. Study Design: Cross sectional study.Setting: Khyber Teaching Hospital Peshawar. Period: 6 months, 1st January 2016 to 30th June2016. Methods: During which FFP transfusion requests made to the blood bank by various unitsof the hospital were studied including general surgery, surgical ICU, general medicine, medicalICU, gynecology and obstetrics. Seventy Six requests were received that were judged using6 variables: indication for FFP use, sampling errors, laboratory analysis errors, interpretationerrors, dosage of FFP (number of units being transfused) and timing of FFP transfusion. Scoreof “1” was given for each correct variable. After matching data to the international protocols, ascore of 4-5 was taken as appropriate and &lt;3 was classified as inappropriate. Results: TwentySeven (35.5%) FFP transfusions were done with a score of 4-5 and were considered appropriatewhile 49(64.5%) FFP transfusions were given a score of 3 or less and were consideredinappropriate. Conclusions: Almost two third of FFP were used inappropriately in our hospital,the commonest indication being acute Disseminated Intravascular Coagulation (DIC) andmostly requested from surgical units. Maximum cases of inappropriate transfusions were dueto wrong sampling techniques and wrong dosage calculations. Most inappropriate transfusionswere done in MICU. It is recommended that annual clinical audit of all blood products usageshould be conducted. Local guidelines for physicians and training programs for nurses andparamedics regarding proper use of blood products should be established.

INAPPROPRIATE USE OF FRESH FROZEN PLASMA AN AUDIT OF A TERTIARY CARE HOSPITAL.

Introduction: As the use of Fresh Frozen Plasma (FFP) is having establishedcomplications including Allergic reactions, infectious complications, hemolysis, fluid overload, transfusion related acute lung injury (TRALI) and immune suppression, therefore it mustbe used cautiously. Objectives: To evaluate the inappropriate use of FFPs, to carry out anaudit of appropriateness of FFP transfusion with reference to international guidelines and setfoundations for blood bank and transfusion protocols. Study Design: Cross sectional study.Setting: Khyber Teaching Hospital Peshawar. Period: 6 months, 1st January 2016 to 30th June2016. Methods: During which FFP transfusion requests made to the blood bank by various unitsof the hospital were studied including general surgery, surgical ICU, general medicine, medicalICU, gynecology and obstetrics. Seventy Six requests were received that were judged using6 variables: indication for FFP use, sampling errors, laboratory analysis errors, interpretationerrors, dosage of FFP (number of units being transfused) and timing of FFP transfusion. Scoreof “1” was given for each correct variable. After matching data to the international protocols, ascore of 4-5 was taken as appropriate and <3 was classified as inappropriate. Results: TwentySeven (35.5%) FFP transfusions were done with a score of 4-5 and were considered appropriatewhile 49(64.5%) FFP transfusions were given a score of 3 or less and were consideredinappropriate. Conclusions: Almost two third of FFP were used inappropriately in our hospital,the commonest indication being acute Disseminated Intravascular Coagulation (DIC) andmostly requested from surgical units. Maximum cases of inappropriate transfusions were dueto wrong sampling techniques and wrong dosage calculations. Most inappropriate transfusionswere done in MICU. It is recommended that annual clinical audit of all blood products usageshould be conducted. Local guidelines for physicians and training programs for nurses andparamedics regarding proper use of blood products should be established.

The AKI-Predict-Score: a new prediction model for acute kidney injury after liver transplantation

Background: Acute kidney injury (AKI) is frequently observed after liver transplantation and associated with impaired long-term outcomes. Although multiple risk factors have been identified, the cumulative impact on development of AKI remains unknown. Our aim was therefore to design a new model to predict the frequency of severe AKI after liver transplantation. Methods: A risk analysis was performed in all patients undergoing primary liver transplantation in two centers (2007–2015; n = 1230). AKI was defined following KDIGO criteria. A new risk score to predict severe AKI (stage 2 & 3) was calculated based on weight of the factors in a multivariable regression analysis according to the Framingham-scheme. Results: Overall, 34% of the recipients developed severe AKI, including 18% requiring renal replacement therapy. Five factors were identified as strongest predictors for severe AKI: donor BMI, DCD graft, recipient BMI, fresh frozen plasma transfusion, and graft implantation time, leading to 0–25 score points with an AUC of 0.7 in the new AKI-Predict-Score (Fig. 1). Three risk classes were identified: low-risk (0–10 points), intermediate-risk (11–20 points) and high-risk with >20 points. In addition, a score of >20 points correlated with impaired long-term graft survival and more postoperative complications assessed with the Comprehensive Complication Index. Conclusion: The AKI-Predict-Score is a new and reliable instrument to identify recipients at risk for severe post-transplant AKI. This score is readily available at end of the transplant procedure. This model offers therefore a great potential to decide which renal protective strategies might be implemented directly after liver transplant.

A Review of Goal-Directed Cardiopulmonary Bypass Management in Pediatric Cardiac Surgery.

Cardiopulmonary bypass perfusion management significantly affects postoperative outcomes. In recent years, the principles of goal-directed therapy have been applied to the field of cardiothoracic surgery to improve patient outcomes. Goal-directed therapy involves continuous peri- and postoperative monitoring of vital clinical parameters to tailor perfusion to each patient's specific needs. Closely measured parameters include fibrinogen, platelet count, lactate, venous oxygen saturation, central venous oxygen saturation, mean arterial pressure, perfusion flow rate, and perfusion pulsatility. These parameters have been shown to influence postoperative fresh frozen plasma transfusion rate, coagulation state, end-organ perfusion, and mortality. In this review, we discuss the recent paradigm shift in pediatric perfusion management toward goal-directed perfusion.

Fresh frozen plasma (Octaplas) and topical heparin in the management of ligneous conjunctivitis

Ligneous conjunctivitis is a rare form of chronic recurrent membranous conjunctivitis with reduced plasminogen activity. It is characterized by the formation of characteristic firm ("woody") membranes on the tarsal conjunctiva. Similar lesions may occur on other mucous membranes. When treated with local excision, ligneous conjunctivitis is invariably associated with recurrences. Various therapeutic modalities, including topical heparin, cyclosporine, fresh frozen plasma (FFP), plasminogen, and amniotic membrane transplantation have been reported to reduce postoperative recurrences. We present 2 cases of recurrent ligneous conjunctivitis in children successfully managed with surgical excision under cover of FFP transfusion, amniotic membrane grafting, and combined with concomitant postoperative administration of topical heparin, steroids.

Novel Alternative Treatment to Plasmapheresis in Evans Syndrome

Evans syndrome is a rare haematological disease characterised by concurrent occurrence of autoimmune haemolytic anaemia (AIHA) and idiopathic thrombocytopenic purpura. The autoimmune haemolysis can lead to hyperbilirubinaemia, profound anaemia and haemodynamic instability. It can be difficult to treat and when refractory to medical treatment it could necessitate emergency splenectomy. Plasmapheresis is used in refractory haemolytic anaemia to aid removal of disease causing autoimmune complexes whilst immunomodulators act to reduce autoantibody response and effectiveness. However, this is an expensive and resource intensive process that is limited to tertiary referral centres. In this case study we present a successful novel alternative for life threatening AIHA in Evans Syndrome using haemofiltration with on-going fresh frozen plasma transfusion when resources are limited or it is not an accessible method.

Transfusion of Fresh Frozen Plasma in Critically Ill Patients: Effective or Useless?

BACKGROUND:Fresh frozen plasma (FFP) is widely used in critically ill patients to correct the deficiency of coagulation factors or increased INR.AIM:In the present study we aimed to evaluate the outcome of the freshly frozen plasma use as prophylaxis in ICU patients before an invasive procedure.METHODS:The study was conducted at Central Anaesthesiology and Intensive Care Service UHCT “Mother Theresa”, Tirana. 136 patients were enrolled with coagulopathy with no bleeding before the invasive procedure, from June 2016 to December 2016. A group of 75 patients underwent a median volume of 12.5 ml/kg FFP given, and 61 had no transfusion. Data were collected on demographics, the severity of illness measured by APACHE III scores, INR, medication use, hemodynamic data.RESULTS:From 136 patients with coagulopathy with no bleeding who underwent planned invasive interventions, 75 [55%] received FFP, vs 61 [45%] p = 0.04 who did not receive. Overall, the median FFP dose was 12.5 ml kg-1. Median INR level in FFP and non-FFP groups was respectively 3.1 (1.9-4.8) and 3.5 (1.8-5.2). INR was corrected in 24 of 75 (32%) of those who received a transfusion. The frequency of minor bleeding episodes was 9.3% in transfused patients vs 4.9% in the non-transfused group. Patients who developed an onset of acute lung injury were more frequent in the FFP group. No allergic transfusion complications were observed. Also, the median length of hospital stay [LOS] was 3.05 days vs 2.91 days and mortality rate 8.2% vs 6.5% with no significant difference between two groups.CONCLUSIONS:Freshly frozen plasma transfusions are often unnecessarily administered during an inadequate correction of the deficiencies of coagulation factors. When comparing a liberal FFP transfusion strategy vs restrictive other clinical trials are required to asses which one is the best to adopt in intensive care settings.

The effect of fluid resuscitation strategy on monocyte and T-cell surface markers

BackgroundDespite initial lifesaving benefits, posttraumatic resuscitation strategies have been associated with immunologic complications leading to systemic inflammatory response syndrome, sepsis, multiple organ failure, and late trauma death. Nevertheless, the direct effect on immunologic surface markers remains inadequately described. We hypothesized that changes in monocyte and T-cell surface markers were associated with initial posttraumatic fluid resuscitation. Materials and methodsData were extracted from the inflammation and host response to injury (Glue Grant) study. Blood samples were drawn from 492 patients on days 0, 1, 4, 7, 14, and 28 and analyzed for 31 monocyte and T-cell surface markers. Resuscitation strategies during the initial 48 h were quantified, including transfusion of packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, and crystalloids. Longitudinal surface marker concentration changes were quantified by the calculation of a within-patient signal intensity change and were associated with resuscitation strategy while controlling confounders. P-values were post hoc corrected using the false detection rate q-value. ResultsThe monocyte surface marker (CD83) trajectory (as measured by a within-patient signal intensity change) was found to be positively associated with volume of PRBCs transfused (q = 0.002) and negatively associated with the transfused volume of FFP (q = 0.004). T-cell surface marker (CD3) was found to be negatively associated with volume of PRBCs transfused (q = 854 × 10−9) and positively associated with the transfused volume of FFP (q = 0.022). Platelets and crystalloid transfusion volumes were not associated with any surface marker trajectories. ConclusionsPRBC and FFP transfusion was associated with opposing effects on CD3 and CD83 trajectories, which may in part explain some of the protective effects of a high FFP:PRBC ratio in trauma-related resuscitation.

Imaging characteristics of nontraumatic spontaneous intramural hematoma of small bowel secondary to warfarin therapy

Objective To investigate the imaging characteristics of nontraumatic spontaneous intramural hematoma of small bowel secondary to warfarin therapy. Methods The retrospective and descriptive study was conducted. The clinical data of 12 patients with nontraumatic spontaneous intramural hematoma of small bowel secondary to warfarin therapy who were admitted to the First People′s Hospital of Wenling (11 patients) and Taizhou Hospital of Zhejiang Province (1 patient) between January 2010 and December 2016 were collected. Patients received plain and enhanced scans of computed tomography (CT). Patients stopped warfarin therapy, received intramuscular injection of vitamin K1 and fresh-frozen plasma transfusion. Observation indicators: (1) primary signs of CT: ① small bowel wall thickening; ② increased density of small bowel wall; (2) secondary signs of CT: intestine lumen stenosis, intestinal pneumatosis, perienteric changes and other concomitant signs; (3) treatment situations. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). Results Twelve patients received total abdomen plain scans of CT, and 7 received total abdomen enhanced scans of CT. (1) Primary signs of CT: ① Small bowel wall thickening. CT of 12 patients showed solitary, homogeneously symmetric, consecutive and diffuse thickening of small bowel wall, including ileal involvement in 7 patients and jejunum involvement in 5 patients. Ascending part of duodenum of 3 patients involved the 2nd and 3rd groups small bowel. The average length of involved small bowel was 30.7 cm (range, 11.0-58.0 cm). There was no multifocal thickening or colonic involvement. Of 12 patients, 10 and 2 showed moderate thickening (thickness was 1.0-2.0 cm) and severe thickening (thickness > 2.0 cm), and the thickest small bowel wall was 2.5 cm. ② Increased density of small bowel wall. Twelve patients showed varying degrees of increased density of small bowel wall, with an average value of 49.7 HU (range, 36.0-63.4 HU). Of 12 patients, homogeneously increased whole layer density of small bowel wall were detected in 4 patients, higher submucous layer density of small bowel compared with serosal layer density in 4 patients, and all of the above characteristics in 4 patients. Enhanced scans of CT in 7 patients showed enhancement in small bowel mucosal layer and serosal layer, no obvious enhancement in the submucous layer of small bowel wall, clear layers, and a target sign when small bowel lumen was perpendicular to scan slice, including 5 patients with obvious enhancement in small bowel mucosal layer, spring-like change, and clear imaging in portal vein phase. (2) Secondary signs of CT: ① Intestine lumen stenosis: 12 patients had varying degrees of intestine lumen stenosis. Five patients were complicated with small bowel obstruction, showing a gas-liquid level. ② Intestinal pneumatosis: 2 of 12 patients showed patchy and mottled gas shadow. ③ Perienteric changes and other concomitant signs: 12 patients showed obviously increased fat density in surrounding area of involved small bowel and corresponding mesenteric area, and indistinct outside small bowel, including 8 with lots of lath-like high density shadow in surrounding area of small bowel and mesenteric area. The varying degrees of hemoperitoneum were seen in 12 patients. (3) Treatment situations: of 12 patients, 9 underwent correct treatments, 8 of them were improved, and 1 of them with persistently severe abdominal pain underwent urgent explorative laparotomy, showing hemorrhage and necrosis, and then underwent surgery; 3 didn′t undergo correct treatment, without improved or severe symptoms. Conclusion Patients undergoing anticoagulant therapy show acute abdominal pain with abnormal coagulation function, small bowel wall thickening and increased density by CT scans, hemoperitoneum complicated with intestine lumen stenosis, small bowel obstruction and hematocele in surrounding area of small bowel and mesenteric area, these are highly indicative of nontraumatic spontaneous intramural hematoma of small bowel secondary to warfarin therapy. Key words: Intramural hematoma of small bowel; Warfarin; Tomography, X-ray computed; Diagnosis; Jejunum