Massive Blood Loss Research Articles

A Literary Review of AsrigdarainAyurvedw.s.r. to Menometrorrhagia

In PrasutitantraOPD, Menometrorrhagia is the most common gynaecological illness. It is a symptom that can be detected in the majority of gynecological issues. The irregular, massive blood loss per vaginum is a symptom of abnormal uterine bleeding. Bleeding in excess of regular amounts and for a longer period of time during the menstrual cycle. Abnormal uterine bleeding is known as Asrigdara in Ayurvedic samhitas, which implies pradirana(extreme excretion) of raja (menses) per vaginum. The causative factor or Dosa In Asrigdarais Vayu, and the vitiated Dhatu Or Dusya is Rakta(blood), or blood is also vitiated. Because the qualities of rakta and pittaare so similar, vitiating Raktawould aggravate pitta as well. As a result, management should be centered on the usage of medications with Kashaya Rasa and Pittashamak Guna.Due to its Stambhanafeature, Kashaya rasais mostly used to treat bleeding symptoms.There is loss of Rakta Dhatu, so we use the drugs and diet that increases Rakta Dhatu.Management mainly based on the principle of Raktastambhakaand Raktavardhaka.

Four-quadrant transverse abdominis plane block: A relatively new frontier for postoperative analgesia after major abdominal surgery

Four-quadrant transverse abdominis plane block: A relatively new frontier for postoperative analgesia after major abdominal surgery

Patient blood management in India - Review of current practices and feasibility of applying appropriate standard of care guidelines. A position paper by an interdisciplinary expert group.

In a developing country like India, with limited resources and access to healthcare facilities, dealing with massive hemorrhage is a major challenge. This challenge gets compounded by pre-existing anemia, hemostatic disorders, and logistic issues of timely transfer of such patients from peripheral hospitals to centers with adequate resources and management expertise. Despite the awareness amongst healthcare providers regarding management modalities of bleeding patients, no uniform Patient Blood Management (PBM) or perioperative bleeding management protocols have been implemented in India, yet. In light of this, an interdisciplinary expert group came together, comprising of experts working in transfusion medicine, hematology, obstetrics, anesthesiology and intensive care, to review current practices in management of bleeding in Indian healthcare institutions and evaluating the feasibility of implementing uniform PBM guidelines. The specific intent was to perform a gap analysis between the ideal and the current status in terms of practices and resources. The expert group identified interdisciplinary education in PBM and bleeding management, bleeding history, viscoelastic and platelet function testing, and the implementation of validated, setting-specific bleeding management protocols (algorithms) as important tools in PBM and perioperative bleeding management. Here, trauma, major surgery, postpartum hemorrhage, cardiac and liver surgery are the most common clinical settings associated with massive blood loss. Accordingly, PBM should be implemented as a multidisciplinary and practically applicable concept in India in a timely manner in order to optimize the use the precious resource blood and to increase patients' safety.

A Case Report on Focal Placenta Accreta: Successful Conservative Management without Using Methotrexate

The incidence of the placenta accreta spectrum has gradually increased in recent years due to the increasing number of caesarean deliveries. Likewise, the technique of a conservative approach to these cases is more common. The conservative approach is known to reduce massive blood loss and the amount of hysterectomy performed. Our case was placenta previa-focal accreta, attached to the posterior wall and cervix. During caesarean section, though gently separating the placenta from the edges, invasive part of the placenta was left attached to the uterine wall. In this case, dealing with the retained invasive placental fragments, we aimed to avoid the side effects of methotrexate which has conflicting studies demonstrating the effect in the resorption of postpartum placental tissue. Four months after surgery, the remaining placental tissue was resected by operative hysteroscopy. This approach shows that placenta previa cases with focal accreta areas can be managed successfully by leaving the invasive part of the placental tissue.

Ensemble Learning Based Postpartum Hemorrhage Diagnosis for 5G Remote Healthcare

The fifth-generation (5G) communications enables various promising applications that was once impossible, e.g. remote healthcare with the help of fast and reliably delivery of medical data. Post-partum hemorrhage (PPH) refers to the massive blood loss after the birthing stage (within 24 hours), i.e. >500ml for the vaginal delivery, and >1000ml for the cesarean section. PPH is by far the most common cause of the mortality rate of pregnant women, as well as a primary cause of current pregnant mortality in China. Despite the great potential of prediction of PPH, there is currently no effective tool based on the limited raw data from the clinical trials. In the study, we retrospectively study the 3842 vaginal delivery cases in 2017 collected from Beijing Obstetrics and Gynecology Hospital, Capital Medical University. In particular, we obtain the prediction based diagnostic model relying on machine learning, and we adopt the ensemble learning to accomplish this task, by combining the results of various candidate methods. According to the experimental results, the accuracy of correct PPH diagnosis would approach 96.7%; the total disseminated intravascular coagulation (DIC) prediction accuracy approaches 90.3%. In this regard, we may conclude the proposed model based on machine learning would allow us to predict successfully the risk of PPH, and assess the critical level of PPH patient. We anticipate our study results would contribute to the reduction the mortality of pregnant women.

Local application of recombinant activated factor VII for massive surgical bleeding

The authors report resection of anaplastic convexital meningioma in a middle-aged woman complicated by expected massive blood loss. The most intense bleeding occurred at the final stage of resection and it was impossible to stop it with traditional approaches. The surgeon pressed a standard tachocomb plate moistened with a diluted solution of recombinant activated factor VII (coagil, Russia) to the most bleeding area for 5 minutes. Subsequently, surgeon replaced finger pressure with a permanent napkin. Hemostatic effect of recombinant activated factor VII following its systemic administration is well known and convincingly proven in many surgical areas including neurosurgery. However, we do not know any descriptions of its local application in neurosurgical patients.

Факторы риска развития перипартальной кардиомиопатии

Study Objective: To assess risk factors of peripartum cardiomyopathy (PCMP) based on the past medical history, genetic predisposition and peculiarities if this pregnancy. Study Design: retrospective cohort case study. Materials and Methods. We have performed a retrospective analysis of pregnancies and labours of 13 patients at V.A. Almazov National Medical Research Centre with PCMP in 2012–2019. For diagnostics and differential diagnosis, we used general, laboratory and instrumental test methods. Results. We have identified such risk factors as family history of cardiovascular pathologies (61.5%), age 35+ years (53.8%), obesity (53.8%), first labour (46.2%), preeclampsia (38.4%), caesarean delivery (23.1%), gestational diabetes mellitus (15.4%), multiple fetation (15.4%), and history of smoking (15.4%). 76.9% of patients had PCMP developed during pregnancy; 23.1% — on day 1–3 postpartum; a significant factor was operative delivery due to obstetrical symptoms; in one case, caesarean section was followed by a massive blood loss resulting from normal placenta abruption. Prevention of preeclampsia with drugs was indicated for one woman, although in 15.4% of patients it was diagnosed during the previous pregnancy, and 38.4% of women had preeclampsia during the current pregnancy. Conclusion. PCMP is a rare pathology with poorly studied ethiology and high risk of maternal mortality. When analysing clinical cases of 13 patients hospitalised with PCMP to V.A. Almazov National Medical Research Centre, we found out a significant number of PCMP risk factors; however, we have not identified any clear evidence of the impact from a certain factor. An important conclusion is the relation between PCMP and preeclampsia, which can be seen both in our study and in studies by foreign researchers; it is a potential platform for further research of this phenomenon. Keywords: peripartum cardiomyopathy, risk factors, pregnancy, labour

The Use of Acute Normovolemic Hemodilution in Clipping Surgery for Aneurysmal Subarachnoid Hemorrhage

The occurrence of coronavirus disease 2019 (COVID-19) has overwhelmed the blood supply chain worldwide and severely influenced clinical procedures with potential massive blood loss, such as clipping surgery for aneurysmal subarachnoid hemorrhage (aSAH). Whether acute normovolemic hemodilution (ANH) is safe and effective in aneurysm clipping remains largely unknown. Patients with aSAH who underwent clipping surgery within 72 hours from bleeding were included. The patients in the ANH group received 400 mL autologous blood collection, and the blood was returned as needed during surgery. The relationships between ANH and perioperative allogeneic blood transfusion, postoperative outcome, and complications were analyzed. Sixty-two patients with aSAH were included between December 2019 and June 2020 (20 in the ANH group and 42 in the non-ANH group). ANH did not reduce the need of perioperative blood transfusion (3 [15%] vs. 5 [11.9%]; P= 0.734). However, ANH significantly increased serum hemoglobin levels on postoperative day 1 (11.5 ± 2.5 g/dL vs. 10.3 ± 2.0 g/dL; P= 0.045) and day 3 (12.1 ± 2.0 g/dL vs. 10.7 ± 1.3 g/dL; P= 0.002). Multivariable analysis indicated that serum hemoglobin level on postoperative day 1 (odds ratio, 0.895; 95% confidence interval, 0.822-0.973; P= 0.010) was an independent risk factor for unfavorable outcome, and receiver operating characteristic curve analysis showed that it had a comparable predictive power to World Federation of Neurosurgical Societies grade (Z= 0.275; P > 0.05). ANH significantly increased postoperative hemoglobin levels, and it may hold the potential to improve patients' outcomes. Routine use of ANH should be considered in aneurysm clipping surgery.

Study of morphological changes in the kidney during modeling of ischemic-reperfusion injuries of the limb and massive blood loss

The article presents the features of morphological disorders of liver tissue on the background of limb ischemia-reperfusion and massive blood loss. The aim of the work was to establish the presence of structural changes and the severity of morphological disorders of internal organs, remote from the primary place of ischemia-reperfusion during modeling the pathological process. The experiment was performed on 33 adult nonlinear white rats weighing 200-250 g, which were on the standard vivarium diet. Experimental animals were simulated with ischemic-reperfusion syndrome of the lower extremity and massive blood loss. Collection of materials was performed 1 h after intervention or release from the tourniquet and on the 1st, 3rd, 7th and 14th days. All interventions were performed under thiopental-sodium anesthesia (40 mg/kg body weight). Mostly structural violations were expressed as disturbance of blood supply of little and middle caliber blood vessels and also in initial dystrophic changes. During comparison of groups, depending on the severity, it was shown that both the isolated use of a tourniquet and massive blood loss had long-term, systemic consequences, however, more expressed in EG-2; single vascular glomeruli were shrunked, endothelial cells of arterioles were slightly damaged. On the 7th and 14th days changes in the structure of EG-1 were mostly absent, although in EG-2 the epitheliocytes of the outer layer of the capsule remained flattened, retained full blood vessels of the venous bed in the interstitium, and the vast majority of epitheliocytes of the excretory tubules were at different stages of hydropic dystrophy with partly desquamation of the epithelium in the gaps of the tubules. Also, the basal membranes of the tubules were not completely visualized, which indicates deep damage in the structures caused by acute ischemia as a result of bleeding. Thus, as combat trauma (blood loss) is in itself a life-threatening factor, the use of a tourniquet due to the development of ischemic-reperfusion process can complicate the course of the primary affection. Knowledge of the periodization of traumatic disease on the background of this pathology is important for the development of sanogenic effects in order to minimize this pathogenic factor.

The role of metabolic adaptation of the functional state of circulating erythron in determining the course of traumatic disease in patients with massive blood loss in polytrauma

Annotation. Metabolic adaptation of the functional state of circulating erythron is an important criterion for predicting the course of traumatic disease in patients with polytrauma, which is accompanied by heavy blood loss. The aim of the study was to increase the effectiveness of treatment of patients with polytrauma with hemorrhagic shock by developing and implementing a differentiated approach to infusion and transfusion therapy, based on elucidation of the mechanisms of systemic oxygen transport in the postoperative period. The index of erythrocyte transformation index, oxygen delivery index as a leading indicator of oxygen transport system in patients of group I who received intensive therapy according to the classical algorithm, in patients of group II who were additionally prescribed ceruloplasmin solution, in patients of group III who were additionally prescribed a solution of D-fructose-1,6-diphosphate sodium salt hydrate. To determine the functional state of erythrocytes and their ability to deform, we used the method of scanning electron microscopy. Statistical data processing was performed using Student’s t-test (for n<100) at a given level of reliability p=0.95. The statistical analysis of the obtained data revealed a probable reduction in the number of doses of heterogeneous erythrocytes received by patients with high blood loss in polytrauma in patients of group II on the background of maximum ability of erythrocytes to transform while maintaining the oxygen delivery index at a satisfactory level. In the future it is planned to study the morphofunctional parameters of erythrocytes in this group of patients.

Anesthesia for surgery in a patient with Knist's dysplasia for severe scoliotic deformity

Kniest dysplasia is a disease that is inherited in an autosomal dominant manner. It manifests itself as dwarfism, scoliotic deformity of the spine, impaired joint mobility, muscle weakness, visual impairment, and sensorineural deafness. As a result of disproportionate trunk shortening, lumbar hyperlordosis and kyphoscoliosis develop, leading to internal organs (respiratory, cardiovascular system) disorders, disability, and reduced life expectancy.
 A case of surgical treatment of a patient with Kniest dysplasia for severe kyphoscoliotic spinal deformity is described. Posterior corrective cross-rod transpediculocorporal screw spondylodesis T3-L5 with bone autoplasty was performed. While planning anesthesia, difficult tracheal intubation was evaluated on the LEMON scale of 7 points high-risk. While performing tracheal intubation, endoscopic techniques were used: videolaryngoscope, intubation bronchoscope, enabling success. Management of intraoperative blood loss was conducted by a complex of measures: laying the patient in the prone position with the release of the abdominal cavity, normothermia, intraoperative hemodilution of azlactone-balanced polyionic solutions to achieve the target hematocrit in the range of 24%26%, and controlled hypotension with blood pressure decreased by 30% from the original hardware blood reinfusion during surgery. Also, on the first postoperative day, fusing tranexamic acid, correcting anemia and deficiency of blood coagulation factors donor components contributed to the success.
 Discussion. When planning surgery and anesthesia, it is necessary to consider the risk of developing malignant hyperthermia, predicting difficult intubation, and complying with the algorithm to ensure airway patency and prevent massive intraoperative blood loss. With a comprehensive approach to patient management, it is possible to achieve rapid rehabilitation and discharge for outpatient treatment. Surgical treatment for rapidly progressing severe kyphoscoliathical spinal deformity can change the quality and duration of life in patients with Kniest syndrome.

Therapeutic effect of thiocetam on the manifestations of ischemia-reperfusion complicated by massive blood loss and mechanical trauma

Among the current medical and social problems, injuries and blood loss occupy a prominent place, causing stress on the antioxidant defenses. Hypoxia, which underlies the pathogenesis of the post-traumatic period of both diseases, leads to a significant imbalance in the work of internal organs. Scientists are increasingly attracted by the need to use a tourniquet or intraoperative ligatures, as reperfusion local and systemic damage develops. Antioxidants are considered a promising means of correction.The aim of the study was to investigate the features of metabolic disorders in the liver in the early post-traumatic period on the background of the use of a tourniquet and the effectiveness of thiocetam correction.Materials and methods. The experiment was perfomed on 130 white male rats (200-250 g), which were divided into 4 groups: control – the CG, the EG-1 – combination of limb ischemia-reperfusion (IR) with blood loss, the EG-2 – combination of limb IR with blood loss and mechanical trauma of the thigh; the EG-3 combination of limb IR, blood loss, mechanical injury and thiocetam administration. The Malonic dialdehide level catalase activity were estimated in the liver.Results. The use of thiocetam, which is able to struggle against of ischemia and lipid peroxidation by reactivating antiradical enzymes: superoxide dismutase, catalase and glutathione peroxidase, had a positive effect on the state of antioxidant and prooxidant units in the organ, located far from the place of primary ischemia-reperfusion. If in the group of untrated animals (the EG-2, where massive blood loss was combined with a thigh fracture and the use of hemostatic tourniquet) in the early period, the MDA level exceeded the CG data in 5,4 times, and on the 7th and 14th days remained high – being higher on 2,1 times and on 2,7 times, then in the EG-3 (group of treated animals) on the 1st day the level of MDA exceeded the CG data in 4,3 times, but on the 7th and 14th days was higher by 90,5 % and 64 % respectively. The supportive effect of thiocetam on the activity of catalase in the liver was also noted. Thus, in EG-2 the level of antioxidant enzyme on the 1st day decreased by 71,7 %, and remained almost at this level throughout the all post-experimental period. As for the group of treated animals, the level of activity on the 1st day after the intervention decreased by 44,7%, and was so for almost the entire period. On the 14th day, it remained reduced compared to the CG by 35,1 %, while in EG-2 this index was lower compared to the CG by 70,5 %.Conclusion. Having the positive effect of the introduction of thiocetam in the ischemic area, we can eventually add new complex, given the world experience, which would affect the development of the inflammatory response and the rheological properties of blood.

Obstetric blood loss: priorities in the choice of infusion solutions

Background. Bleeding accounts for 34 % of maternal mortality. Every 7 minutes 1 woman dies from bleeding during the labour. Retrospective analysis of medical records shows that in 60-80 % of cases, fatal consequences can be avoided. Criteria for defining the concept of “massive blood loss” are the loss of 100 % of circulating blood volume (CBV) within 24 hours or 50 % of CBV within 3 hours, loss of 150 ml/min, of 2 % of body weight within 3 hours, reduction of hematocrit by 10 % in combination with hemodynamic disturbances, one-time blood loss more than 1500-2000 ml or 25-35 % CBV, the need for transfusion of >10 doses of erythromass for 24 hours. The main causes of bleeding in obstetrics include uterine atony, premature placental abruption, uterine rupture, placental abruption, hereditary blood diseases, coagulopathy, sepsis, amniotic fluid embolism.
 Objective. To describe infusion therapy (IT) for obstetric bleeding.
 Materials and methods. Analysis of literature data on this issue.
 Results and discussion. Strategies for the treatment of obstetric hemorrhage include restriction of the traditional massive crystalloid-based IT, applying the principle of antihypertensive resuscitation, using of adequate doses of tranexamic acid, fibrinogen concentrate and prothrombin complex concentrate, early informed use of blood components, and low-volume IT. Routine use of unbalanced crystalloid solutions in critically severe patients is dangerous. Infusion of large amounts of 0.9 % NaCl may cause metabolic hyperchloremic acidosis. Therefore, except in cases of hypochloremia, it is advisable to replace saline with balanced solutions. Reosorbilact (“Yuria-Pharm”) is the most suitable solution for this purpose. It mobilizes the own fluid of the organism, helping it to move from the intercellular space into the vessels. Hypotensive resuscitation involves the introduction of limited amounts of fluid in the early stages of treatment of hemorrhagic shock (until the bleeding stops). Low-volume IT program is a part of hypotensive resuscitation. In this case, the following solutions can be used: Reosorbilact, Sorbilact, Gekoton (“Yuria-Pharm”), 130/0.4 hydroxyethyl starch (HES), hypertonic NaCl solutions (including combined solutions with colloids), polyhydric alcohols. It should be noted that the new generation of HEC has less effect on coagulation than older drugs. Due to the risk of kidney damage, HEC solutions should be used in the lowest effective dose for as shortest period of time as possible. HEC infusion should be stopped as soon as hemodynamic targets are reached. Solutions containing polyhydric alcohols (Reosorbilact, Sorbilact, Xylate) occupy an important position in IT of critically ill patients. Due to their high osmolarity, Reosorbilact and Sorbilact cause fluid to move from the intercellular space into the vascular bed, improving microcirculation and tissue perfusion. The polyhydric alcohol sorbitol contained in these solutions creates increased osmotic pressure in the renal tubules, which provides a diuretic effect. In case of the blood loss volume of I-II functional class up to 1500 ml and stopped bleeding, IT is performed in a limited mode. The volume of intravenous infusion together with blood components should not exceed 200 % of the blood loss volume. Reosorbilact (10-15 ml/kg) is an initial solution in combination with 0.9 % NaCl (20-30 ml/kg). In case of unstable hemodynamics HEC may be added (up to 1,5 L). Blood components are used only in case of confirmed coagulopathy and continued bleeding. In case of massive critical blood loss >1500-2000 ml, it is advisable to use the protocol of massive blood transfusion 1:1:1:1. In order to reduce the pathological response of the endothelium to IT, it is advisable to use a substrate for the nitric oxide synthesis, namely, Tivortin (“Yuria-Pharm”). To stop life-threatening obstetric bleeding, CBV must be refilled using the protocol of massive blood transfusion and automatic blood reinfusion, oxytocin and prostaglandin analogues for the correction of uterine tone, uterine massage, correction of coagulopathy, balloon tamponade of the uterus.
 Conclusions. 1. Emergency care for massive bleeding in obstetrics is one of the priorities in reducing maternal morbidity and mortality. 2. Intensive therapy of blood loss should be based on modern recommendations and the use of modern drugs. 3. The indications for transfusion of blood components should be clearly applied.

Comparison between dexmedetomidine and propofol for sedation during mechanically ventilated patients after major intraabdominal surgeries: An observational study

Introduction: Major complex intraabdominal surgeries which have prolonged intraoperative surgical duration and wide hemodynamic fluctuations so they required an elective mechanical ventilation in view of large fluid shift and massive blood loss. So such large group of patients for providing conscious sedation two most popular agents dexmedetomidine and propofol are being used because their mechanisms of action and pharmacokinetic properties are different. Aims and Objectives: Primary aim of our study is to assess the duration of mechanical ventilation in both study group (D or P) following major intraabdominal surgery. The secondary aim was to evaluate total duration of intensive care unit as well as hospital stay, incidence of delirium and any additional sedative agent. Materials and Methods: All patients on arrival to the ICU and after fulfilling the inclusion and exclusion criteria following completion of major intraabdominal surgeries they were allocated, randomly using sealed envelopes techniques into two groups each comprising of 15 patients, to receive intravenous infusions of either dexmedetomidine or propofol and plan for elective mechanical ventilation. Statistical analysis: All data’s was statistically analysed using Minitab® 16 (Minitab, Inc., State College, PA) software. Results: In our study variables like demographic profile, baseline hemodynamics and ASA status were comparable in both the study groups. Our study results showed that total duration of mechanical ventilation was much earlier in the dexmedetomidine group compared to propofol (7.62 hours vs. 11.23 hours, P 0.05). The incidence of delirium were more in patient receiving propofol group (6.6% vs. 20%, P = 0.346). Conclusion: This study concluded that for any complex major intraabdominal surgeries dexmedetomidine has significant reduction in time on mechanical ventilation but no significant difference was seen in terms of incidence of delirium, duration of ICU or hospital stay and mortali

Theory of hibernament ensembles and the possibility of its use to ensure life activity for extremal impacts

The possibility of efficient use of the theory of hibernation ensembles to ensure vital activity in extreme conditions is considered. Hibernation ensembles are strictly selected sets of tools, among which are special combinations of pharmacological preparations and hypostabilizers, respiratory mixtures different in gas composition, controlled hypothermia, etc., which, when coordinated, cause the formation of a special state of the body, referred to as «hypobiosis and cryobiosis» or artificial hibernation. The data of experimental studies on changes in the body’s resistance to the extreme effects of gamma radiation, to acute hypobaric hypoxia and to flight overloads under conditions of artificially induced hibernation are generalized to determine the possibility of using the theory of hibernation ensembles while ensuring vital activity under extreme influences. It is shown that under the influence of vegetotropic agents against the background of hypothermia, the metabolic processes slow down significantly and the organism of warm-blooded animals begins to acquire ambient temperature. The condition that occurs in this case is accompanied by an increase in the body’s resistance to extreme factors, such as acute hypobaric hypoxia, deep hypothermia, exposure to ionizing radiation, toxic lesions, massive blood loss, pain shock, etc. This area of research is of particular relevance for the development of methods for long-term life support person in extreme conditions, with severe injuries and in the provision of medical care in conditions of mass admission victims, since it provides a reserve of time necessary for organizing the safe transportation of victims to the places of specialized and high-tech medical care, that is, actually providing medical care at a later date.

Patient blood management

Background. Blood transfusions (BT) remain one of the most common medical procedures: about 110,000 doses of whole blood are collected annually and almost as many are transfused. Approximately every 10th patient who undergoes invasive procedures in the hospital needs BT. However, 40-60 % of BT in patients without bleeding are inappropriate.
 Objective. To describe modern views on the BT.
 Materials and methods. Analysis of the literature on this issue.
 Results and discussion. The triad of major risk factors for perioperative complications includes three interrelated factors: blood loss, anemia, and BT. The use of blood products is accompanied by an increase in the number of complications (not directly related to BT) and 30-day mortality. Fatal consequences of blood transfusion are also possible. They include acute lung damage associated with BT, hemolytic and bacterial complications, circulatory overload, anaphylaxis. Patient blood management (PBM) includes early detection and treatment of preoperative anemia, especially in patients at high risk of bleeding; minimization of blood loss and maximally blood-saving tactics; rational and guideline-adequate administration of allogenic blood products. About 39 % of patients scheduled for surgery have preoperative anemia. Absolute iron deficiency (ID) is present in 62 % of patients with preoperative anemia. Ferritin level <30 μg/L is an indicator of such anemia. Preoperative anemia is an independent risk factor for mortality and complications, so in presence of anemia, major emergency surgery should be postponed until hemoglobin returns to normal. The target level of the latter in the treatment of preoperative anemia should be 130 g/L for both sexes. If surgery is scheduled 6-8 weeks after the revealing of ID with or without anemia, oral replacement therapy should be performed. Parenteral forms of iron are used if there are <6 weeks left before the planned operation or the hemoglobin level is <100 g/L. If necessary, BT can be performed according to a liberal (BT is prescribed at a hemoglobin level <90-100 g/L) or restrictive (<70-80 g/L) strategy. According to a large-scale meta-analysis, the latter almost halves the risk of erythromass transfusion compared to the former. As recommended by the National Institute for Health and Care Excellence, it is advisable to apply a single-dose strategy with reassessment of BT requirements after each blood transfusion. Decisions in patients with chronic BT-dependent anemia and cancer should be made individually. The use of intravenous iron supplements before surgery can reduce the number of BT in the postoperative period. Sufer (“Yuria-Pharm”) is a trivalent iron for intravenous use, which effectively, quickly and safely increases hemoglobin levels. As it was mentioned, another element of the PBM is the minimization of blood loss. Tranexamic acid preparations (Sangera, “Yuria-Pharm”) can be prescribed for this purpose. Tranexamic acid is a lysine-like inhibitor of fibrinolysis; it is recommended for the prevention of bleeding with expected moderate and severe blood loss (>500 ml). In patients with trauma with massive blood loss or with a high risk of intracranial hemorrhage, it is also advisable to use tranexamic acid. Its activity is 26 times higher than the activity of aminocaproic acid. Tranexamic acid is highly effective; it reduces the need for BT without increasing the risk of thrombosis.
 Conclusions. 1. The triad of major risk factors for perioperative complications includes three interrelated factors: blood loss, anemia, and BT. 2. PBM includes early detection and treatment of preoperative anemia, minimization of blood loss and adequate administration of allogenic blood products. 3. In conditions of preoperative anemia, it is advisable to correct diabetes with oral or parenteral forms of iron. 4. Tranexamic acid drugs are prescribed to minimize blood loss.

Erupted abscess cavity and stenosed pulmonary homograft in repeated radical sternotomies: Anaesthesia and haemodynamics control

Congenital heart disease affects approximately 1% of the population and is the leading cause of birth defect associated infant illness and death. The most common cyanotic heart disease is tetralogy of Fallot (TOF) which is characterized by overriding of aorta, ventricular septal defect (VSD), pulmonary stenosis and right ventricular hypertrophy. TOF are repaired early in infancy and involves closure of the VSD and repair or replacement of the pulmonary valve to improve right ventricular outflow. A potential and significant complication is stenosis of the pulmonary homograft. We discuss a young patient with previous sternotomies for repair of TOF presenting for his 4th redo-sternotomy for an infective abscess near his old pulmonary homograft. This case presents to us multiple challenges such as a septic patient, previous sternotomies and a potential for intraoperatively massive blood loss. Keywords: Anaesthesia, Cardiac, Heart, Redo-sternotomy, Sepsis.

Role of Vasopressin Injection Intramyometrial in Decreasing Blood Loss During Abdominal Myomectomy (A Randomized Controlled Trial)

Background: Abdominal myomectomy is a major operation. Massive blood loss is the most serious complication which should be taken in consideration to decrease morbidity and mortality. There are several modalities to decrease blood loss approached in different studies as preoperative GnRh, uterine artery tourniquet, tranexamic acid, vasopressin …etc.Aim: The aim of the study was to assess the role of vasopressin injection intramyometrial in decreasing blood loss during abdominal myomectomy. The study was done on women who were scheduled for abdominal myomectomy in Ain-Shams University Maternity Hospital.Materials and Methods: This study is a randomized clinical trial study which was conducted at Ain-Shams University Maternity Hospital on 60 women with uterine fibroid admitted for abdominal myomectomy to detect if vasopressin injection intramyometrial had a role in decreasing blood loss versus placebo or not.Results: The end results showed that that the mean of blood loss was 826.67cc with standard deviation 185.94 and 115.53cc with standard deviation 23.17 at control and vasopressin group respectively with p- value <0.001 which indicates that there a highly significant difference in blood loss between two groups. The mean reduction in hemoglobin was1.38 and 0.08 g/dl in control and vasopressin group respectively with p- value < 0.002 which showed that there was a significant difference between them, only 30% of the control group need blood transfusion and no need for transfusion in the vasopressin group.Conclusion:Intramyometrial vasopressin injection during abdominal myomectomy may effectively decreases the blood loss, need for blood transfusion and it causes less reduction in haemoglobin and haematocrit. Thereby it seems to be an effective method without having any risk of ischemic damage to the uterus.

Intraplacental Fetal Vessel Diameter May Help Predict for Placental Invasiveness in Pregnant Women at High Risk for Placenta Accreta Spectrum Disorders.

Background Prenatal identification of placenta accreta spectrum (PAS) disorder is essential for treatment planning. More objective means for predicting PAS and clinical outcome may be provided by MRI descriptors. Purpose To investigate the association of intraplacental fetal vessel (IFV) diameter at MRI with PAS and peripartum complications. Materials and Methods Between March 2016 and October 2019, 160 gravid women suspected of having PAS underwent placental MRI as part of a prospective trial. Secondary analysis was performed by two experienced genitourinary radiologists for presence and maximum diameter of IFVs. Relative risk ratios were computed to test the association of IFVs with presence and depth of PAS invasiveness. Receiver operating characteristic analysis was used to evaluate the ability of IFV diameter to help predict PAS, placenta percreta, and peripartum complications and for comparison of the area under the curve (AUC) versus that from other combined MRI predictors of PAS (eg, myometrial thinning, intraplacental T2-hypointense bands, uterine bulge, serosal hypervascularity, and signs of extrauterine placental spread). Intraoperative and histopathologic findings were the reference standard. Results A total of 155 women were evaluated (mean age, 35 years ± 5 [standard deviation]; mean gestational age, 32 weeks ± 3). PAS was diagnosed in 126 of 155 women (81%) (placental percreta in 68 of 126 [54%]). At delivery, 30 of 126 women (24%) experienced massive blood loss (>2000 mL). IFVs were detected at MRI in 109 of 126 women with PAS (86%) and in 67 of 68 women with placental percreta (98%). The relative risk ratio was 2.4 (95% CI: 1.6, 3.4; P < .001) for PAS and 10 (95% CI: 1.5, 70.4; P < .001) for placental percreta when IFVs were visible. IFVs of 2 mm or greater were associated with PAS (AUC, 0.81; 95% CI: 0.67, 0.95; P = .04). IVFs of 3 mm or greater were associated with placenta percreta (AUC, 0.81; 95% CI: 0.73, 0.89; P < .001) and with peripartum complications, including massive bleeding (AUC, 0.80; 95% CI: 0.71, 0.89; P < .001). Combining assessment of IFVs with other MRI descriptors improved the ability of MRI to predict PAS (AUC, 0.94 vs 0.89; P = .009). Conclusion Assessment of intraplacental fetal vessels with other MRI descriptors improved the ability of MRI to help predict PAS. Vessel diameter of 3 mm or greater was predictive of placenta percreta and peripartum complications. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Dighe in this issue.

A Modified VATS Procedure for Treating Adult Intralobar Pulmonary Sequestration.

Video-assisted thoracoscopic surgery (VATS) makes it possible to treat intralobar sequestration (ILS) more minimally invasive compared with conventional open surgery. However, this procedure is challenging to expose and isolate the aberrant arteries of ILS and the risk of bleeding is high. Herein, we developed a modified VATS procedure in which the aberrant vessels are treated in the last step of lobectomy, rather than at the beginning. In this way, we can expose the aberrant vessels easier and reduce the risk of massive blood loss, also simplifying the surgical procedure.