Hemostatic Control Research Articles

S3692 What the Heil? H. heilmanni Causing Peptic Ulcer Disease and Severe GI Bleeding

Introduction: Helicobacter pylori (H. pylori) has a well-known association with peptic ulcer disease (PUD) and gastritis. However, other helicobacter species cause similar diseases. We present a case of a patient with H. heilmanni infection causing PUD and significant gastrointestinal (GI) bleeding. Case Description/Methods: A 63-year-old man with CAD s/p stent on aspirin and recent root canal procedure who was taking ibuprofen for several weeks presented with a one day history of mixed melena and hematochezia. He had no prior history of PUD or GI bleeding. EGD revealed two Forrest class III gastric ulcers and three duodenal ulcers including a 7 mm Forrest class IIc ulcer. Gastric biopsies were taken. He required 3 units of packed red blood cells (PRBCs), and was discharged on pantoprazole BID with a Hgb of 8 g/dl and biopsy results pending. The following day, he presented with similar symptoms, requiring ICU admission for Hgb 5.4 g/dl and blood pressure 77/52 mm Hg. He required 5 units PRBCs without pressor support. Repeat EGD revealed a 12 mm Forest class IIb duodenal ulcer (image 1) which was injected with epinephrine, and a single hemoclip was placed with hemostatic control. Prior EGD biopsy results showed chronic gastritis and helicobacter-like species found to be Helicobacter heilmanni by genotyping, and negative for concurrent H. pylori. The patient was treated with triple therapy with pantoprazole, amoxicillin and clarithromycin. Repeat EGD 2 months after treatment confirmed eradication of H. heilmanni and healing of all ulcers. Discussion: H. heilmanni was first described as an organism causing gastritis in humans in 1987 under its former name Gastrospirillum hominis. H. heilmanni is found in less than 1% of patients undergoing EGD for upper GI symptoms compared to H. pylori which is found in as many as 60% of patients with similar symptoms. Complications of H. heilmanni infection in patients include: 82% developing gastritis, 16% PUD, 2% gastric cancer, and, in our patient’s case, severe GI bleeding. Concurrent infection with H. pylori and H. heilmanni infection is uncommon and identification of H. heilmanni via H. pylori via stool antigen or rapid urease testing has unclear efficacy. Our case highlights the need for H. heilmanni to be recognized as a potential cause of PUD and further testing might need to be considered when H. pylori testing is negative. Ultimately, definitive diagnosis is done via genetic PCR amplification, and treatment is possible using the same antibiotic regimen as H. pylori.Figure 1.: Duodenal ulcer with adherent clot (Forest class IIb).

Identification of Aedes aegypti salivary gland proteins interacting with human immune receptor proteins.

Mosquito saliva proteins modulate the human immune and hemostatic systems and control mosquito-borne pathogenic infections. One mechanism through which mosquito proteins may influence host immunity and hemostasis is their interactions with key human receptor proteins that may act as receptors for or coordinate attacks against invading pathogens. Here, using pull-down assays and proteomics-based mass spectrometry, we identified 11 Ae. aegypti salivary gland proteins (SGPs) (e.g., apyrase, Ae. aegypti venom allergen-1 [AaVA-1], neutrophil stimulating protein 1 [NeSt1], and D7 proteins), that interact with one or more of five human receptor proteins (cluster of differentiation 4 [CD4], CD14, CD86, dendritic cell-specific intercellular adhesion molecule-3-grabbing non-integrin [DC-SIGN], and Toll-like receptor 4 [TLR4]). We focused on CD4- and DC-SIGN-interacting proteins and confirmed that CD4 directly interacts with AaVA-1, D7, and NeST1 recombinant proteins and that AaVA-1 showed a moderate interaction with DC-SIGN using ELISA. Bacteria responsive protein 1 (AgBR1), an Ae. aegypti saliva protein reported to enhance ZIKV infection in humans but that was not identified in our pull-down assay moderately interacts with CD4 in the ELISA assay. Functionally, we showed that AaVA-1 and NeST1 proteins promoted activation of CD4+ T cells. We propose the possible impact of these interactions and effects on mosquito-borne viral infections such as dengue, Zika, and chikungunya viruses. Overall, this study provides key insight into the vector-host (protein-protein) interaction network and suggests roles for these interactions in mosquito-borne viral infections.

Successful Reconstruction of a Ruptured Brachial Artery Aneurysm With Superficial Femoral Vein

A 50 year old male on chronic haemodialysis through a brachiocephalic arteriovenous fistula was transferred because of pain and symptoms of median nerve compression (A and B, asterisk). Duplex scanning noted a ruptured brachial artery (A, arrow) with a maximum diameter of 30 mm. After achieving haemostatic control the median nerve was separated from the aneurysmal wall and the aneurysm was resected. (B) A 4–5 cm length of reversed superficial femoral vein (arrow) was used for brachial artery reconstruction to prevent infection. The great saphenous vein was not used because of diameter mismatch with the dilated brachial artery.Image 1

HIGH-POWER DIODE LASER FOR CLINICAL MANAGEMENT IN RARE SYNDROME PRESENTING RECURRENT GINGIVAL FIBROMATOSIS

Barber-Say syndrome (SBS) is extremely rare, affecting less than 20 people worldwide. It has an autosomal dominant inheritance, classified as a subtype of ectodermal dysplasia, associated with mutations in the Twist-2 gene. The following clinical characteristics seen in SBS are as follows: a marked facial dysmorphology, hypertrichosis, hypertelorism, atrophic/redundant skin, bulbous nose, dental anomalies, and gingival fibromatosis. The patient performs gingivectomy annually since she was 9 years old. At the age of 17, she returned for another intervention, and a high-powered laser (HPL) (DMC, Diode, 808 nm, 1.5W) was used. During the procedure, there were no complications, with excellent hemostatic control and absence of postoperative pain. After 2 years of follow-up, she has no recurrences. We conclude that, in cases of gingival fibromatosis associated with syndromes, HPL promotes greater comfort in the postoperative period in addition to increasing the time interval between procedures.

Tissue response to different incision tools in animal model.

The aim of this study is to compare the repair of incisions performed with microdissection electrocautery tip, conventional electrocautery tip, high potency diode laser, and conventional scalpel blade in a in vivo model. Different incisions were performed in adults Holtzman rats using the four types of instruments: microdissection electrocautery tip, conventional electrocautery tip, high potency diode laser, and conventional scalpel blade, in different periods of healing process. Thirty rats were divided into 5 groups, according to the period of euthanasia-24h, 48h, 72h, 7days, and 14days. All animals received four incisions, each by a different method. Quantitative histological and histomorphometric analyses were performed using hematoxylin and eosin (HE) and Picrosirius Red staining. Inflammatory profile and tissue repair presented small statistically significance differences comparing conventional scalpel blade and microdissection tip; moreover, both presented quantitatively superior to the others. It is believed that the microdissection tip can perform a dynamic incision just as a common scalpel blade, but more effective. Furthermore, it can promote a better hemostatic control of the surgical field that is comparable to conventional electrocautery tip without affecting tissue repair.

PEGylated Polyester Nanoparticles Trigger Adverse Events in a Large Animal Model of Trauma and in Naı̈ve Animals: Understanding Cytokine and Cellular Correlations with These Events.

Intravenously infusible nanoparticles to control bleeding have shown promise in rodents, but translation into preclinical models has been challenging as many of these nanoparticle approaches have resulted in infusion responses and adverse outcomes in large animal trauma models. We developed a hemostatic nanoparticle technology that was screened to avoid one component of the infusion response: complement activation. We administered these hemostatic nanoparticles, control nanoparticles, or saline volume controls in a porcine polytrauma model. While the hemostatic nanoparticles promoted clotting as marked by a decrease in prothrombin time and both the hemostatic nanoparticles and controls did not active complement, in a subset of the animals, hard thrombi were found in uninjured tissues in both the hemostatic and control nanoparticle groups. Using data science methods that allow one to work across heterogeneous data sets, we found that the presence of these thrombi correlated with changes in IL-6, INF-alpha, lymphocytes, and neutrophils. While these findings might suggest that this formulation would not be a safe one for translation for trauma, they provide guidance for developing screening tools to make nanoparticle formulations in the complex milieux of trauma as well as for therapeutic interventions more broadly. This is important as we look to translate intravenously administered nanoparticle formulations for therapies, particularly considering the vascular changes seen in a subset of patients following COVID-19. We need to understand adverse events like thrombi more completely and screen for these events early to make nanomaterials as safe and effective as possible.

P1658: DELAYED REVERSAL OF FACTOR V INHIBITOR ACTIVITY POST-IMMUNOSUPPRESSIVE THERAPY, FOLLOWED BY A SUCCESSFUL PREGNANCY: A CASE REPORT

Background: Acquired factor V inhibitor (AFVI) is a very rare autoimmune hemostatic disorder that leads to hemorrhagic manifestations of variable severity. Aims: We describe a case of a 35-year-old Caucasian female patient presenting with severe AFVI with life-threatening hemorrhages. The AFVI exhibited spontaneous reversal over several years after discontinuation of ineffective combination immunosuppressive therapies and subsequently a successful pregnancy. Methods: Diagnosis of AFVI was based on a marked prolongation of prothrombin time-international normalized ratio (INR) and activated partial thromboplastin time (APTI) not corrected by the addition of normal plasma (1:1 ratio), with FV activity reduced to <1.0%. Other coagulation factor activity levels were unchanged, and the presence of an FV inhibitor was revealed by the Bethesda inhibitor assay. Results: Over the course of 2.5 years, plasmapheresis plus immunoglobulins and different combination immunosuppressive regimens were adminstered (dexamethasone+rituximab; cyclophosphamide+dexamethasone + rituximab + cyclosporine; cyclosporine + sirolimus + cyclophosphamide + dexamethasone; bortezomib+sirolimus+methylprednisolone; sirolimus+mycophenolate mofetil). Coagulation could be effectively maintained using recombinant FVIIa. The combination immunosuppressive therapies resulted in intermittent reversal of AFVI over 2.5 years, which then became therapy-resistant. After discontinuation of the unsuccessful immunosuppressive therapies, the patient exhibited partial spontaneous remission: her FV activity gradually increased from ~1% to ~33% over the course of 5 years. The patient became pregnant and during her pregnancy, FV activity increased to 54%, and her coagulation parameters were normalized. She gave birth to a healthy child by Caesarean section without any bleeding complications. Summary/Conclusion: Patients with AFVI presenting with hemorrhagic manifestations should be treated aiming for hemostatic control as well as inhibitor eradication. The use of an activated bypassing agent for hemostatic control is effective in AFVI. The presented case is unique because the treatment regimens used included combinations of multiple immunosuppressive agents and also suggest that patients with AFVI resistant to combination immunosuppressive protocols receiving no therapy may undergo spontaneous remission. Long-term monitoring of the coagulation status and the anti-FV inhibitor levels is warranted.

Utilization of emicizumab in acquired hemophilia A: A case report

BackgroundAcquired Hemophilia A (AHA) is a rare autoimmune disorder associated with the development of autoantibodies against factor VIII (FVIII). Although obtaining hemostatic control through the use of recombinant factor VIIa, activated prothrombin complex concentrate and recombinant porcine FVIII are cornerstones in the clinical management of AHA, these therapies have several disadvantages, including a higher risk for the development of thromboembolic events, unpredictable efficacy and short half-lives. While emicizumab has been FDA licensed for use in bleeding prophylaxis for patients with Congenital Hemophilia A (CHA) with and without inhibitors, it has not been approved for use in AHA, with only a few reports describing its use in this context. Case reportWe report our experience with the use of emicizumab in an 83-year old male with AHA, complicated by the onset of atrial fibrillation following admission, drug-induced thrombocytopenia, infectious complications, and the identification of a low-grade lymphoproliferative disorder, in which emicizumab prophylaxis was used for bleeding prophylaxis in the context of persistently elevated inhibitor titers without evidence of thrombotic events or thrombotic microangiopathy.

Prostatic artery embolization in men with severe hemophilia a: a case report of two patients

BackgroundThis is the first case report describing the peri- and postoperative hemostasis plans in two men with severe hemophilia A (HA) who underwent prostatic artery embolization (PAE) for symptomatic benign prostatic hyperplasia (BPH).Case presentationTwo patients with severe HA and lower urinary tract symptoms (LUTS) not responding to medical therapy underwent PAE at our institution. In both patients, intermittent administration of decreasing doses of extended half-life recombinant factor VIII (EHL rFVIII) concentrate from 30 min before to 7 days after the PAE resulted in good hemostatic control. In addition to EHL rFVIII, tranexamic acid was administered in the same timeframe to augment the action of EHL rFVIII and to account for possible mucosal bleeding from the urinary tract. Both patients reported a minor localized hematoma at the femoral puncture site in the right groin, that resolved spontaneously. No other bleeding complications were observed.ConclusionsThe procoagulant effects of the chosen dosing of EHL rFVIII showed sufficient to perform a technically successful embolization. At 6 months follow-up, both patients had significant reduction in self-reported urinary symptoms and were content with the outcome.

Recombinant von Willebrand factor prophylaxis in patients with severe von Willebrand disease: phase 3 study results

AbstractInternational guidelines conditionally recommend long-term prophylaxis in patients with von Willebrand disease (VWD) and severe and frequent bleeding. As recombinant von Willebrand factor (rVWF; vonicog alfa) may reduce the frequency of treated spontaneous bleeding events (BEs), we investigated the efficacy and safety of rVWF prophylaxis in adults with severe VWD. Patients with BEs requiring VWF therapy in the past year (on-demand VWF therapy [prior on-demand group] or plasma-derived VWF prophylaxis [pdVWF; switch group]) were enrolled in a prospective, open-label, nonrandomized, phase 3 study. The planned duration of rVWF prophylaxis was 12 months; starting rVWF dose was 50 ± 10 VWF: ristocetin cofactor (VWF:RCo) IU/kg twice weekly (prior on-demand group) or based on prior pdVWF weekly dose/dosing frequency (switch group). The primary endpoint was annualized bleeding rate (ABR) of treated spontaneous BEs (sABR) during rVWF prophylaxis. Over the 12-month study period, treated sABR decreased by 91.5% on-study vs historical sABR in 13 patients in the prior on-demand group, and by 45.0% in 10 patients in the switch group (model-based analysis ratio, 0.085; 95% confidence interval [CI], 0.021-0.346 and 0.550; 95% CI, 0.086-3.523, respectively). No treated spontaneous BEs were recorded in 84.6% (11/13) and 70.0% (7/10) of patients, respectively. The safety profile of rVWF was consistent with the previously established profile, with no new adverse drug reactions identified. Findings suggest that rVWF prophylaxis can reduce treated spontaneous BEs in patients previously receiving on-demand VWF therapy and maintains at least the same level of hemostatic control in patients who switch from prophylaxis with pdVWF to rVWF, with a favorable safety profile. This trial was registered at www.clinicaltrials.gov (#NCT02973087) and www.clinicaltrialsregister.eu (#EudraCT 2016-001478-14).

Single versus double Perclose techniques for vascular closure during transfemoral transcatheter aortic valve replacement.

The preferred approach for transcatheter aortic valve replacement (TAVR) is transfemoral. There has been widespread adoption of the Perclose ProglideTM device for vascular closure. Typically, two devices are deployed before upsizing the access sheath in the "preclose technique." Prior investigations have compared the use of a single device versus double device technique, but none have shown significant clinical benefit to either approach. Five hundred and sixpatients underwent transfemoral TAVR (TF-TAVR) with single or double Perclose devices for vascular closure from July 2015 to February 2020. A retrospective review was conducted, and propensity-matched analyses were used to account for differences in baseline characteristics. In the matched analysis, there were 251 patients in the single Perclose group and 238 in the double. There was a statistically significant improvement in overall procedural success using the single closure device (94.6% vs. 88.5%, p = 0.009)This was defined as intraprocedural hemostatic control, lack of contrast extravasation, arterial dissection, occlusion, or stenosis >50% in the final crossover angiogram, as well as unimpaired limb perfusion without claudication throughout the index hospitalization. There was also a significant improvement in arterial dissection rates (0.6% vs.4.6%, p = 0.004), stenosis >50% (1.3% vs. 4.4%, p = 0.028), and Valve Academic Research Consortium major vascular complications (1.8% vs. 4.9%, p = 0.038). A single Perclose device is a safe means of vascular closure during TF-TAVR and may have important clinical benefits compared to the commonly used two-device technique.

Anti-TFPI for hemostasis induction in patients with rare bleeding disorders, an ex vivo thrombin generation (TG) guided pilot study

BackgroundRare bleeding disorders (RBD) are inherited coagulopathies, whose hemostatic control is based upon replacement therapy. Marstacimab (PF-06741086) is a human monoclonal IgG that targets the Kunitz2 domain of tissue factor pathway inhibitor [TFPI]. Marstacimab is currently in development for bleeding prophylaxis in patients with hemophilia. ObjectivesTo assess the potential impact of Marstacimab upon thrombin generation (TG) in RBD patients' plasma samples. ResultsOur cohort included 18 RBD patients, with severe deficiencies: 5 Von Willebrand Disease (VWD) type 3, 4 FVII, 3 FXI, 2 FXIII deficiency and 1 patient with: FX, FV + FVIII, Fibrinogen, combined vitamin K dependent factors' deficiency. Citrated samples from RBD patients were collected and spiked with Marstacimab, TG was measured by calibrated automated thrombogram. Among all patients a reduced baseline TG was observed as compared to controls. Improvement of median (lag time, peak and ETP was observed in Marstacimab spiked samples from 8 min, 99 nM, 1116 nMx min to 5.5 min, 194 nM,1614 nMx min, respectively. None of the values measured among RBD patients exceeded normal controls. ConclusionThese in vitro data suggest that Marstacimab may serve as a promising approach for restoring the hemostatic balance in various RBD, though potential clinical implications should be further investigated.

Outcomes after eversion of sac and subtotal excision of sac in cases of primary hydrocele

Background/Aim: Hydrocele is a common disease worldwide, and an effective treatment for it is surgery. The commonly performed procedures for its treatment are a) excisional technique — subtotal excision of the sac and b) Jaboulay’s procedure — eversion of the hydrocele sac. This study aimed to evaluate the merits and demerits of eversion of the sac versus subtotal excision in terms of complications, postoperative hospital stays, and recurrence rate. Methods: This prospective study was conducted at a large surgical center. Patients who presented with scrotal swelling and were diagnosed as primary hydrocele cases constituted the study population (100 in all). Subtotal excisions or eversions of the sac were performed depending on the type of hydrocele encountered preoperatively. Follow-up was done at 1week, 1 month, 3 months, and 6 months postoperatively. Results: Eversion of the sac was done in 70 cases, and subtotal excision was done in 30 cases. Incidence of edema, intense pain, and hematoma formation was higher in the group undergoing excision of the sac compared to those undergoing eversion of the sac. The average postoperative hospital stay was 3–5 days in the eversion group. The average postoperative hospital stay was 7–9 days in the subtotal excision group. No recurrence was noted in either of the study groups during the stays study period. Conclusion: Eversion of the sac was associated with fewer postoperative complications, minimal tissue handling, and good hemostatic control compared to subtotal excision of the sac. Patients who underwent eversion of the sac received earlier discharge than those undergoing a subtotal excision of the sac for primary vaginal hydrocele.

Resection of five centimeter cesarean scar ectopic pregnancy and isthmocele repair using vascular clamps

The objective of this video is to present a surgical case of resection and repair of a five centimeter cesarean scar ectopic pregnancy. We will highlight the use of laparoscopic vascular bulldog clamps to aid in hemostatic control during the resection. We will also demonstrate the use of laparoscopic suturing and intracorporeal knot tying techniques to repair the hysterotomy incision and help prevent formation of a postoperative isthmocele. We will present the case of a 33 you G4P1021 that presented with a five centimeter cesarean scar ectopic pregnancy. She failed medical management and had a strong desire for future fertility. We will present a surgical approach to the resection and repair of a cesarean scar ectopic pregnancy. We will highlight the use of laparoscopic vascular bulldog clamps to aid in the isolation and temporary occlusion of the vascular supply to aid in the hemostatic resection of the ectopic pregnancy. We will also demonstrate laparoscopic suturing and knot tying techniques to approximate the hysterotomy incision and prevent formation of a post operative isthmocele. Resection of a cesarean scar ectopic pregnancy with repair is a viable treatment option for patients that have failed medical therapy and desire future fertility. Laparoscopic vascular bulldog clamps can aid in a hemostatic excision and repair. Sound surgical principles and laparoscopic suturing techniques can be employed to prevent the formation of a postoperative isthomcele.

Hysterectomy strategies for cesarean scar ectopic pregnancy

The objectives of this film are to discuss both medical and surgical management options for c-section scar ectopic pregnancy and understand the importance of hemostatic control and methods to decrease bleeding. Although there is no consensus on appropriate management, there are several options. Expectant management is reported, but successful outcome with no complications is unlikely. Systemic methotrexate and local injection have low success rates. Uterine artery embolization is an adjuvant treatment used to decrease bleeding. Dilation and curettage can be combined with methotrexate. Hysteroscopic resection and laparoscopic resection are additional options. If patient no longer desires fertility, hysterectomy is considered. This is the case of a 34 year old G6P3 at 7 weeks and 5 days gestation with cesarean section scar ectopic found incidentally on ultrasound during prenatal visit. She had a history of three cesarean sections. Patient declined methotrexate and desired hysterectomy. When performing a hysterectomy for a c-section scar ectopic, it is important to prioritize bleeding control. In this case, the uterine manipulator was not placed into the uterus initially, to avoid perforating the pregnancy. Instead, an EndoPaddle was used from above through an assist port to manipulate the uterus without causing trauma and bleeding. The goal is to achieve hemostasis before introducing a uterine manipulator by ligating the uterine arteries at the origin via retroperitoneal dissection. Vasopressin injection into pregnancy implantation site achieves additional hemostasis. In conclusion, taking extra precautions to control bleeding is essential during a hysterectomy for cesarean scar ectopic pregnancy.

The what, why and when of wide awake local anaesthesia no tourniquet surgery.

Wide awake local anaesthesia no tourniquet, also known as WALANT, is the practice of performing surgery under local anaesthetic in the absence of a tourniquet. This technique uses the vasoconstrictive effects of adrenaline and the local anaesthetic effects of lignocaine to establish a Bier block with haemostatic control. Permitting active patient participation intraoperatively, wide awake local anaesthesia no tourniquet surgery improves patient compliance with rehabilitation and yields higher patient satisfaction. With reduced cost and equipment requirements, this method improves accessibility for patients and productivity for healthcare institutions. This is of particular benefit within the current COVID-19 climate, as wide awake local anaesthesia no tourniquet technique provides a means of overcoming restrictions to theatre access and anaesthetic support. This review delves into the current uses of wide awake local anaesthesia no tourniquet surgery, outlining the initial conception of the practice by Canadian surgeons. The advantages and disadvantages are considered, and potential future applications of this technique are discussed.

Orthotopic Liver Transplantation Using Allografts from Donors with Recent Liver Trauma Injury: A Nationwide Snapshot from the French Cristal Biomedecine Agency Registry

Introduction: In the current setting of organ shortage, brain dead liver donors with recent liver injury (RLI) represents a potential pool of donors. Yet, data on safety of liver transplantation (LT) using grafts with RLI are lacking. Methods: All liver grafts from brain-dead donors with RLI proposed for LT between 2010 and 2018 were identified from the nationwide CRISTAL registry of the Biomedicine Agency. The current study aimed at evaluating both feasibility and safety of LT with 1-year survival as the primary endpoint. Results: Among 11073 LT, 142 (1.2%) using grafts with RLI were performed. These 142 LT including 23 split LT were performed from 131 donors (46.1%) out of 284 donors with RLI proposed for LT. Transplanted grafts were procured from donors with significantly lower liver enzymes levels (p<0.001) and less advanced liver trauma according to the AAST liver grading system (p=0.013) as compared to not transplanted grafts. Before allocation, 19 (6.7%) out of 284 donors underwent damage control intervention. During transplantation, surgical management directed to the liver was reported in 19 patients (13%), consisting in local hemostatic control (n=15), partial hepatic resection (n=3) or perihepatic packing (n=1). Ninety-day mortality and severe morbidity rates were 8.5% (n=12) and 29% (n=42), respectively. One-year OS and GS rates were 85% and 84%. Five-year OS and GS rates were respectively of 77% and 74%. Conclusion: Using grafts from donors with RLI appears safe with acceptable long-term outcomes. All brain-dead patients with multiorgan trauma including liver injury should be considered for organ allocation.

Hemostatic effects of traditional Inula viscosa and Capsella bursa-pastoris plant mixture extract on rat liver parenchymal bleeding model.

Failure to achieve effective bleeding control and problems related to transfusion in liver surgery are the most common causes of post-operative mortality and morbidity. Various methods/drugs including topical hemostatic agents have been em-ployed for bleeding control in liver surgery. This study was aimed to investigate the hemostatic properties of the herb mixture extract of Inula viscosa and Capsella bursa-pastoris (IvCbp) in rat liver laceration model, which have been traditionally used as antiseptic and hemostatic agents public in Hatay/Tukey. Thirty rats were divided into three groups equally and blood samples were taken from all rats for preoperative hemoglobin (Hb) measurements. Then, the standard liver resection model was applied to all rats. Sponge for the first rat group, Ankaferd Blood Stopper® Trend-Tech for the second rat group and IvCbp plant extract mixture for the third group were applied to resection areas for 3 minutes. Liver samples of all rats were evaluated in terms of inflammation and necrosis intensity on the 5th post-operative day. Post-operative Hb values were found as 11.0±1.1 g/dL in the sponge group, 11.9±2.0 g/dL in the Ankaferd group, and 14.1±1.2 g/dL in the IvCbp herb mixture group (p<0.001). In the histopathological examination, less necrosis was observed in the herb mixture group compared to the sponge and Ankaferd groups (p=0.001). In addition, no statistically significant necrosis difference was observed between sponge and Ankaferd groups. While less inflammation was observed in the herb mixture group compared to the other groups, Ankaferd group had the highest inflammation score (p<0.001). IvCbp herb mixture extract group provide effective hemostatic control, caused less Hb decrease and resulted in less inflammation and necrosis compared to Ankaferd and sponge groups in a rat liver resection model.

“Packing” torácico en urgencias torácicas

Damage control is defined as an approach with 3 stages in patients with life-threatening injuries. Stage I: abbreviated laparotomy for hemorrhage and contamination control. Stage II: intensive care management to correct physiologic abnormalities; and stage III: definitive repair of injuries. Thoracic packing, an adaptation of abdominal packing, was described as a temporary procedure for hemostatic control. The aim of this study is to report our experience with thoracic packing and show its usefulness in thoracic damage control surgery. Traumatic chest injuries vary from minor trauma to life-threatening injuries. The decision to perform thoracic packing is made during the contact with a critically ill patient. In conclusion, packing is effective for bleeding control in critically ill patients who are not suitable for definitive treatment.

Optimizing Tourniquet Pressure in Upper Extremity Surgery.

Background: Pneumatic tourniquet is an effective tool to achieve hemostatic control of the surgical field in upper extremity (UE) operations. Elevated pressures have been associated with adverse effects despite various methods of pressure determination. We aim to demonstrate the usage of reduced tourniquet pressures and examine factors associated with achieving reduced pressures. Methods: A prospective study was conducted (2016-2018) at a Level 1 Trauma Center and an Outpatient Surgical Center, totaling 226 operations, involving a reduction of cuff pressures over time from a standard baseline of limb occlusion pressure for UE operations. Results: A gradual reduction of pressures was successfully achieved with a mean pressure of 187 mmHg and average time of tourniquet application being 25 minutes. We found chronological surgical number and patient BMI to be significantly associated with tourniquet pressure (p < 0.05). 4.5% of cases resulted in breakthrough bleeding, but did not reliably occur with any pressure thresholds, patient demographics, or operative factors (p > 0.05, for all). Conclusions: Reduced tourniquet pressures can mitigate complications associated with tourniquet use. Our research shows reduced pressures are successful in maintaining field visibility and we encourage an adoption of pressures below 200 mm Hg in most procedures that require a tourniquet.