Massive Blood Transfusion Research Articles

TULAREMIA PRESENTING AS LARGE GI ULCERATION AND HEMORRHAGE

TULAREMIA PRESENTING AS LARGE GI ULCERATION AND HEMORRHAGE

S3435 Jejunal Diverticula: A Lesser Known Cause for Massive Lower GI Bleeding

Introduction: Small bowel diverticula are rare. We describe a case of Jejunal diverticula that caused massive lower GI bleeding requiring surgical intervention. Case Description/Methods: A 77 year old male presented to our ER with sudden onset bright red blood per rectum. The patient first noticed 2 days ago that his stool was dark red followed by red streaking on toilet paper. A few hours later he developed rectal urgency followed by another large bloody bowel movement along with associated diaphoresis, LLQ cramping and presyncope. Past medical history included GERD, BPH, Hypertension and Polycythemia Vera. He had never undergone an EGD and his last screening colonoscopy was normal 5 years ago. Labwork revealed acute anemia with Hb of 7.7 g/dL (baseline 13) and one unit of RBCs was therefore transfused. Emergent EGD and colonoscopy were performed and these were unremarkable apart from sigmoid diverticulosis. The following day massive rectal bleeding recurred and this time a radionuclide bleeding scan was obtained which was positive for active bleeding in small bowel lumen at the LUQ. Interventional Radiology did not feel the area was approachable for embolization. 6 additional units of RBCs were given due to persistent bleeding. General Surgery was called and the patient was taken to OR for exploratory laparotomy with small bowel resection. Diffuse proximal Jejunal diverticulosis was found to be actively bleeding with blood traveling all the way to distal colon. 60 cm of Jejunum was transected 30 cm from the ligament of Treitz. The patient had an unremarkable postoperative recovery with no further episodes of bleeding and stable Hemoglobin on serial CBCs. Discussion: Diverticulosis involving the small bowel, especially the Jejunum, is rare. These lesions have a higher incidence in the elderly and are acquired as a result of increased intraluminal pressure. They are thin and friable due to lack of muscularis layer. Concurrent colonic diverticulosis is common. Traditionally considered to be asymptomatic and incidental findings on imaging or surgical exploration, Jejunal diverticula can uncommonly cause lower GI bleeding. Traditional endoscopy is unhelpful given the lack of accessibility of the small bowel. CT Angiography and Nuclear Medicine bleeding scans may be beneficial to localize bleeding. Hemorrhage is usually brisk, requiring massive blood transfusion to maintain hemodynamics. Unstable patients should undergo emergent laparotomy so that resection of the involved segment can be performed.

The haemostatic effect of deep-frozen platelets versus room temperature-stored platelets in the treatment of surgical bleeding: MAFOD—study protocol for a randomized controlled non-inferiority trial

BackgroundThe Netherlands Armed Forces have been successfully using deep-frozen (− 80 °C) thrombocyte concentrate (DTC) for the treatment of (massive) bleeding trauma patients in austere environments since 2001. However, high-quality evidence for the effectiveness and safety of DTCs is currently lacking. Therefore, the MAssive transfusion of Frozen bloOD (MAFOD) trial is designed to compare the haemostatic effect of DTCs versus room temperature-stored platelets (RSP) in the treatment of surgical bleeding.MethodsThe MAFOD trial is a single-blinded, randomized controlled non-inferiority trial and will be conducted in three level 1 trauma centres in The Netherlands. Patients 12 years or older, alive at hospital presentation, requiring a massive transfusion including platelets and with signed (deferred) consent will be included. The primary outcome is the percentage of patients that have achieved haemostasis within 6 h and show signs of life. Haemostasis is defined as the time in minutes from arrival to the time of the last blood component transfusion (plasma/platelets or red blood cells), followed by a 2-h transfusion-free period. This is the first randomized controlled study investigating DTCs in trauma and vascular surgical bleeding.DiscussionThe hypothesis is that the percentage of patients that will achieve haemostasis in the DTC group is at least equal to the RSP group (85%). With a power of 80%, a significance level of 5% and a non-inferiority limit of 15%, a total of 71 patients in each arm are required, thus resulting in a total of 158 patients, including a 10% refusal rate. The data collected during the study could help improve the use of platelets during resuscitation management. If proven non-inferior in civilian settings, frozen platelets may be used in the future to optimize logistics and improve platelet availability in rural or remote areas for the treatment of (massive) bleeding trauma patients in civilian settings.Trial registrationClinicalTrials.gov NCT05502809. Registered on 16 August 2022.

P9.14: Massive Blood Transfusion: Risk Factors and Consequences

Introduction: Massive blood transfusion (MBT) is a common occurrence in liver transplant patients. Recipient-related risk factors include cirrhosis, history of multiple surgeries and suboptimal donors. And, while advances in surgical techniques, anaesthetic management and graft preservation have decreased the need for transfusions, this complication has not been completely eliminated. Materials and Methods: One thousand four hundred and sixty nine liver transplants were performed at our institution between May 1998 and December 2019, and data was available regarding transfusion for 1469 of them. We divided the patients into two groups, with regards to transfusion of 6 or more units of packed red blood cells in the first 24 hours post transplant, and we analyzed the differences between the groups. We analyzed the risk factors for massive transfusion, as well as factors that influence patient survival by using Cox regression. Results: Out of the 1198 patients, 607 (50.7%) met criteria for massive transfusion.Both groups were statistically different with regards to hepatocellular carcinoma, autoimmune cause, liver/kidney transplant, uDCD, retransplantation, albumin serum levels, creatinine, sodium, bilirubin, haemoglobin, platelets, INR, MELD, McCluskey and Child scores. Out of the variables from the McCluskey index, only the following were significant for massive bleeding: Haemoglobin <10, INR >2 and creatinine >1.2. We contrasted the efficiency of all of the previously mentioned scores for capacity to predict massive transfusion, but none reached an area below the curve above 0.7. Survival was statistically lower at 1, 3, and 5 years when comparing the groups that had MBT compared to those that did not (92,6%, 85,2% and 79,7% respectively in the non MBT group, vs. 78,1%, 71,6% y 66,8%, respectively, in the MBT group). Regarding survival analysis, MBT was associated with a 1.5 mortality risk as opposed to no MBT. Conclusion: Massive blood transfusion impacts patient survival in a statistically significant way. The most significant risk factors are preoperative haemoglobin, INR and creatinine.

P9.17: New Index for Prediction of Massive Blood Transfusion

P9.17: New Index for Prediction of Massive Blood Transfusion

Massive blood transfusion following older adult trauma: The effect of blood ratios on mortality.

Massive blood transfusion (MBT) following older adult trauma poses unique challenges. Despite extensive evidence on optimal resuscitative strategies in the younger adult patients, there is limited research in the older adult population. We used the Trauma Quality Improvement Program (TQIP) database from 2013 to 2017 to identify all patients over 65 years old who received a MBT. We stratified our population into six fresh-frozen plasma:packed red blood cell (FFP:pRBC) ratio cohorts (1:1, 1:2, 1:3, 1:4, 1:5, 1:6+). Our primary outcomes were 24-h and 30-day mortality. We constructed multivariable regression models with 1:1 group as the baseline and adjusted for confounders to estimate the independent effect of blood ratios on mortality. A total of 3134 patients met our inclusion criteria (median age 73 ± 7.6 years, 65% male). On risk-adjusted multivariable analysis, 1:1 FFP:pRBC ratio was independently associated with lowest 24-h mortality (1:2 odds ratio [OR]1.60, 95% confidence interval [CI]1.25-2.06, p < 0.001) and 30-day mortality (1:2 OR 1.44, 95% CI 1.15-1.80, p=0.002). Compared to all other ratios, the 1:1 FFP:pRBC ratio had the lowest 24-h and 30-day mortality following older adult trauma consistent with findings in the younger adult population.

Clinical Value of Early Viscoelastometric Point-of-Care Testing During Postpartum Hemorrhage for the Prediction of Severity of Bleeding; A Multicenter Prospective Cohort Study in the Netherlands

(Acta Obstet Gynecol Scand. 2021;100:1656–1664) Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide. Early intervention before the development of coagulopathy can reduce hemostatic impairments, preventing the need for interventions including hysterectomy and massive blood transfusion. Tests currently used during PPH to evaluate clotting status include the FIBTEM and fibrinogen measurement. Results from these tests unfortunately can take up to an hour, during which time significant blood may be lost. Results of clot firmness from FIBTEM at 5 minutes (A5 measurement) can indicate the potential for PPH in only 15 minutes. In this multicenter study in the Netherlands researchers compared blood loss within 24 hours of birth to the results of these tests to determine accuracy in predicting severe PPH with blood loss ≥2000 mL.

Validation of 5 models predicting transfusion, bleeding, and mortality in liver transplantation: an observational cohort study.

Historically, orthotopic liver transplantation (OLT) has been associated with massive blood loss, blood transfusion and morbidity. In order to predict such outcomes five nomograms have been published relating to transfusions and morbidity associated with OLTs. These nomograms, developed on the basis of three cohorts of patients consisting of 406, 750, and 800 having undergone OLTs, aimed to predict a transfusion of ≥1 red blood cell unit (RBC), a transfusion of >2 RBC units, a blood loss of >900ml, as well as one-month and one-year survival rates. The aim of this study was to validate these five nomograms in a contemporary, independent cohort of patients. Five nomograms were previously developed based on 406, 750, and 800 OLTs. In this study we performed a temporal validation of these nomograms on contemporary patients that consisted of three cohorts of 800, 250, and 200 OLTs. Logistic regression coefficients from the historic development cohorts were applied to the three contemporary temporal validation cohorts. The most accurate nomogram was able to predict transfusion of ≥1 RBC units with an area under the curve (AUC) was 0.91. The second-best nomogram was able to predict bleeding of >900ml with an AUC of 0.70. T he AUC of the third nomogram (transfusion of >2 RBC units) was 0.70. However, is temporal validation was suboptimal, due to a low prevalence of OLTs transfused with >2 RBC units. The last 2 nomograms exhibited clearly suboptimal AUC values of 0.54 and 0.61. Two of the five nomograms predict blood transfusion and blood loss with excellent accuracy. Transfusion of ≥1 RBC unit and blood loss of >900ml can be predicted on the basis of these nomograms. However, these nomograms are not accurate to predict one-month and one-year survival rates. These results should be further cross-validated, ideally prospectively, in additional external independent cohorts.

Machine learning-based prediction of massive perioperative allogeneic blood transfusion in cardiac surgery.

Massive perioperative allogeneic blood transfusion, that is, perioperative transfusion of more than 10 units of packed red blood cells (pRBC), is one of the main contributors to perioperative morbidity and mortality in cardiac surgery. Prediction of perioperative blood transfusion might enable preemptive treatment strategies to reduce risk and improve patient outcomes while reducing resource utilisation. We, therefore, investigated the precision of five different machine learning algorithms to predict the occurrence of massive perioperative allogeneic blood transfusion in cardiac surgery at our centre. Is it possible to predict massive perioperative allogeneic blood transfusion using machine learning? Retrospective, observational study. Single adult cardiac surgery centre in Austria between 01 January 2010 and 31 December 2019. Patients undergoing cardiac surgery. Primary outcome measures were the number of patients receiving at least 10 units pRBC, the area under the curve for the receiver operating characteristics curve, the F1 score, and the negative-predictive (NPV) and positive-predictive values (PPV) of the five machine learning algorithms used to predict massive perioperative allogeneic blood transfusion. A total of 3782 (1124 female:) patients were enrolled and 139 received at least 10 pRBC units. Using all features available at hospital admission, massive perioperative allogeneic blood transfusion could be excluded rather accurately. The best area under the curve was achieved by Random Forests: 0.810 (0.76 to 0.86) with high NPV of 0.99). This was still true using only the eight most important features [area under the curve 0.800 (0.75 to 0.85)]. Machine learning models may provide clinical decision support as to which patients to focus on for perioperative preventive treatment in order to preemptively reduce massive perioperative allogeneic blood transfusion by predicting, which patients are not at risk. Johannes Kepler University Ethics Committee Study Number 1091/2021, Clinicaltrials.gov identifier NCT04856618.

Transsplenic Splenic Artery Embolization for Persistent Pseudoaneurysm after Proximal Splenic Artery Embolization

A 42-year–old man with necrotizing pancreatitis underwent a cystogastrostomy complicated by acute hemorrhage, requiring massive blood transfusion. Angiography showed a splenic artery pseudoaneurysm (Fig 1), and the splenic artery proximal to the pseudoaneurysm was embolized with coils. The patient continued to bleed and was transferred to our institution where he underwent embolization of the right gastroepiploic artery. Computed tomography angiography showed persistent filling of the pseudoaneurysm, which had increased in size from 7 to 13 mm (Fig 2).

SURG-01. The Tentative Application of En Bloc concept in the Pediatric Brain Tumor: A Retrospective Study of 171 Cases from A Large Pediatric Center in China

BACKGROUND: The less allowable blood loss and tolerance of intraoperative blood loss of children lead to the high rate of massive blood transfusion. The surgical concepts of en bloc resection may contribute to the improvement of brain tumor resection. OBJECTIVE: To investigate the effects of en bloc concept on short outcomes of pediatric brain tumors and factors associated with the application of en bloc concept. METHODS: According to the surgical concept involved, the patients were divided into three subgroups-complete en bloc concept, partial en bloc concept and piecemeal concept. The matching-comparison(en bloc group consisting of the first two subgroups and piecemeal group) was conducted to investigate the effect of the en bloc concept on the short-term outcomes. Then the patient data after January 2018, when the en bloc concept was routinely integrated into brain tumor surgery in our medical center, were reviewed and analyzed to find out the predictors associated with the application of en bloc concept. RESULTS: In the en bloc group, the perioperative outcomes, including hospital stay(p=0.001), PICU stay(p=0.003), total blood loss(p=0.015), transfusion rate(p=0.005) and complication rate(p=0.039), were all significantly improved. The multinomial logistic regression analysis showed that tumor volume, bottom vessel, and imaging features, like encasing nerve or pass-by vessel, finger-like attachment, ratio of “limited line” and ratio of “clear line” remained independent predictors for the application of en bloc concept in our medical center. CONCLUSION: The application of en bloc concept based on the imaging features can improve the short-term outcomes.

Damage control laparotomy outcomes in a major urban trauma centre

BACKGROUND: Damage control laparotomy (DCL) is associated with high mortality. The purpose of this study was to review the outcomes of DCL. METHODS: All patients undergoing DCL for penetrating trauma from May 2015 to July 2017 were reviewed. Data retrieved were demographics, mechanism of injury, vitals, and biochemical parameters. Injury severity was described by the revised trauma score (RTS), penetrating abdominal trauma index (PATI), injury severity score (ISS) and trauma and injury severity score (TRISS). Indications for DCL, length of ICU stay, number of procedures and primary abdominal closure rates, complications and mortality were recorded. RESULTS: Fifty-one patients underwent DCL and 47 patients sustained gunshot injuries. Indications for laparotomy were haemodynamic instability (n = 27) and peritonism in stable patients (n = 22). The medians for the different severity scores were RTS 7.36, ISS 20, and PATI 30. The organs most commonly injured, in decreasing frequency, were small bowel (33), large bowel (25), abdominal vasculature (22), liver (18), stomach (14), kidney (10), diaphragm (10), spleen (9) and pancreas (8). DCL procedures performed were abdominal packing (36), temporary bowel ligation (30), vascular (5) and ureteric (1) shunting. The median number of laparotomies performed per patient was three, with a primary fascial closure rate of 69%. The mortality rate was 29%. CONCLUSION: DCL in our centre is associated with a 29% mortality rate. Severe acidosis, massive blood transfusion in first 24 hours and median PATI score more than 47 are independent risk factors associated with increased mortality.

Acute respiratory distress syndrome

There are several medical conditions that directly or indirectly lead to pulmonary destruction or acute lung injury or Acute Respiratory Distress Syndrome e.g. Sepsis, Inhalation of harmful substances, severe pneumonia, Head, chest, or another major injury, Pancreatitis (inflammation of the pancreas), massive blood transfusions and burns. Due to some incidences involved in the etiology of ARDS and limited information about the epidemiology, recognition, management, and less significant results regarding patients with acute respiratory distress syndrome (ARDS), shows intense research on ARDS is needed. From an earlier time, this syndrome has been given many names, including congestive atelectasis, traumatic adult respiratory distress syndrome and shock lung. Recently, the new definition of ARDS has been published, and this definition suggested severity-oriented respiratory treatment by introducing three levels of severity consistent with PaO2/FiO2 and positive end-expiratory pressure. Lung-protective ventilation is still the key to a better outcome in ARDS. ARDS is said to a selection of etiologies, carries high morbidity, mortality (10to 90%), and financial cost. This review is an attempt to compile all aspects of the management of ARDS.

Advancing Prediction of Risk of Intraoperative Massive Blood Transfusion in Liver Transplantation With Machine Learning Models. A Multicenter Retrospective Study.

BackgroundLiver transplantation surgery is often accompanied by massive blood loss and massive transfusion (MT), while MT can cause many serious complications related to high mortality. Therefore, there is an urgent need for a model that can predict the demand for MT to reduce the waste of blood resources and improve the prognosis of patients.ObjectiveTo develop a model for predicting intraoperative massive blood transfusion in liver transplantation surgery based on machine learning algorithms.MethodsA total of 1,239 patients who underwent liver transplantation surgery in three large grade lll-A general hospitals of China from March 2014 to November 2021 were included and analyzed. A total of 1193 cases were randomly divided into the training set (70%) and test set (30%), and 46 cases were prospectively collected as a validation set. The outcome of this study was an intraoperative massive blood transfusion. A total of 27 candidate risk factors were collected, and recursive feature elimination (RFE) was used to select key features based on the Categorical Boosting (CatBoost) model. A total of ten machine learning models were built, among which the three best performing models and the traditional logistic regression (LR) method were prospectively verified in the validation set. The Area Under the Receiver Operating Characteristic Curve (AUROC) was used for model performance evaluation. The Shapley additive explanation value was applied to explain the complex ensemble learning models.ResultsFifteen key variables were screened out, including age, weight, hemoglobin, platelets, white blood cells count, activated partial thromboplastin time, prothrombin time, thrombin time, direct bilirubin, aspartate aminotransferase, total protein, albumin, globulin, creatinine, urea. Among all algorithms, the predictive performance of the CatBoost model (AUROC: 0.810) was the best. In the prospective validation cohort, LR performed far less well than other algorithms.ConclusionA prediction model for massive blood transfusion in liver transplantation surgery was successfully established based on the CatBoost algorithm, and a certain degree of generalization verification is carried out in the validation set. The model may be superior to the traditional LR model and other algorithms, and it can more accurately predict the risk of massive blood transfusions and guide clinical decision-making.

Risk factors and prediction of acute kidney injury after liver transplantation: Logistic regression and artificial neural network approaches.

BACKGROUNDAcute kidney injury (AKI) has serious consequences on the prognosis of patients undergoing liver transplantation. Recently, artificial neural network (ANN) was reported to have better predictive ability than the classical logistic regression (LR) for this postoperative outcome. AIMTo identify the risk factors of AKI after deceased-donor liver transplantation (DDLT) and compare the prediction performance of ANN with that of LR for this complication. METHODSAdult patients with no evidence of end-stage kidney dysfunction (KD) who underwent the first DDLT according to model for end-stage liver disease (MELD) score allocation system was evaluated. AKI was defined according to the International Club of Ascites criteria, and potential predictors of postoperative AKI were identified by LR. The prediction performance of both ANN and LR was tested. RESULTSThe incidence of AKI was 60.6% (n = 88/145) and the following predictors were identified by LR: MELD score > 25 (odds ratio [OR] = 1.999), preoperative kidney dysfunction (OR = 1.279), extended criteria donors (OR = 1.191), intraoperative arterial hypotension (OR = 1.935), intraoperative massive blood transfusion (MBT) (OR = 1.830), and postoperative serum lactate (SL) (OR = 2.001). The area under the receiver-operating characteristic curve was best for ANN (0.81, 95% confidence interval [CI]: 0.75-0.83) than for LR (0.71, 95%CI: 0.67-0.76). The root-mean-square error and mean absolute error in the ANN model were 0.47 and 0.38, respectively. CONCLUSIONThe severity of liver disease, pre-existing kidney dysfunction, marginal grafts, hemodynamic instability, MBT, and SL are predictors of postoperative AKI, and ANN has better prediction performance than LR in this scenario.

Shock index as a predictor for mortality in trauma patients: a systematic review and meta-analysis.

The primary aim was to determine whether a shock index (SI) ≥ 1 in adult trauma patients was associated with increased in-hospital mortality compared to an SI < 1. This systematic review including a meta-analysis was performed in accordance with the PRISMA guidelines. EMBASE, MEDLINE, and Cochrane Library were searched, and two authors independently screened articles, performed the data extraction, and assessed risk of bias. Studies were included if they reported in-hospital, 30-day, or 48-h mortality, length of stay, massive blood transfusion or ICU admission in trauma patients with SI recorded at arrival in the emergency department or trauma center. Risk of bias was assessed using the Newcastle-Ottawa Scale, and the strength and quality of the body of evidence according to GRADE. Data were pooled using a random effects model. Inter-rater reliability was assessed with Cohen's kappa. We screened 1350 citations with an inter-rater reliability of 0.90. Thirty-eight cohort studies were included of which 14 reported the primary outcome. All studies reported a significant higher in-hospital mortality in adult trauma patients with an SI ≥ 1 compared to those having an SI < 1. Twelve studies involving a total of 348,687 participants were included in the meta-analysis. The pooled risk ratio (RR) of in-hospital mortality was 4.15 (95% CI 2.96-5.83). The overall quality of evidence was low. This systematic review found a fourfoldincreased risk of in-hospital mortality in adult trauma patients with an initial SI ≥ 1 in the emergency department or trauma center.

Hemostatic Markers as Predictors of Massive Blood Transfusion in Orthotopic Liver Transplantation

The aim of this study was to determine which standard preoperative laboratory results correlate to intraoperative transfusion requirement during orthotopic liver transplantation (OLT). We retrospectively analyzed data from 305 adult patients who underwent OLT between 2009 and 2013 using laboratory results: International Normalization Ratio, platelet count, fibrinogen, and hemoglobin and total blood transfusion requirements (group L ≤ 1 L, group M > 1 L). All statistical analyses were conducted using the Statistical Package for Social Sciences software (IBM Corp. Released 2012. IBM SPSS for Windows, Version 21.0; IBM Corp., Armonk, NY, United States). We found a positive correlation with hemoglobin and fibrinogen using multivariate analysis (P < .001). The receiver operating characteristic analysis in favor of total blood replacement > 1 L has shown a correlation with fibrinogen (cut-off value of 2.3 g/L, sensitivity of 85.8%, and specificity of 37.4%) and hemoglobin (cut-off 111 g/L, sensitivity of 69.9%, and specificity of 71.6%). This study has confirmed that preoperative fibrinogen and hemoglobin level, but not International Normalization Ratio and platelet count, are indicators of potential massive perioperative blood loss during OLT and that within our patient cohort a cut-off fibrinogen value of 2.3 g/L and Hb level of 110g/L can predict a blood replacement of >1 L.

Injury mechanisms and injury severity scores as determinants of urban terrorism-related thoracoabdominal injuries.

Improving the care of injuries resulting from terrorist attacks requires understanding injury mechanisms in armed conflicts. The aim of this study was to identify injury characteristics in military personnel with thoracoabdominal combat injuries resulting from terrorist attacks in urban settings. A retrospective study of military personnel with thoracoabdominal injuries who were referred to a tertiary center after treating and stabilizing at a primary healthcare organization due to terror-related injuries in various urban regions of Turkey between June 2015 and December 2016 was performed. A total of 70 patients were included in this study, of whom 87.1% were injured by explosives and 12.9% (n= 9) had gunshot wounds (GSWs). Mean injury severity score (ISS) was 21, blood transfusion amount was 3.7 units, and mortality rate was 8.5%. Patients injured by explosives had most commonly abdominal and extremity injuries (31.1%), whereas isolated abdominal injuries (55.6%) were observed among patients with GSWs. There were no significant differences between the mechanisms of injuries and the ISS, blood transfusion, and mortality (p= 0.635, p= 0.634, and p= 0.770, respectively). A significant correlation was observed between the ISS and transfusion amounts (r= 0.548, p <0.001). Mortality was significantly higher in those with a high ISS and those undergoing massive blood transfusions (p= 0.004 and p <0.001, respectively). Explosive injuries, concomitant vascular injuries, high ISS, and the need for massive transfusions increased the mortality rate in urban combat injuries. To quickly identify high-risk patients and improve the care of injuries, it is essential to use predictive models or scoring systems.

The impact of a multilevel approach to reduce emergency hysterectomy for postpartum haemorrhage: Insights from a tertiary referral centre in Northern Italy

ObjectiveTo assess the effectiveness of the implementation of a multilevel institutional program to reduce the rate of emergency peripartum hysterectomy (EPH) secondary to postpartum haemorrhage (PPH) in a Western world referral centre for obstetrics. Study designWomen who delivered at a tertiary care regional obstetric hub in Milan between 2012 and 2020 were retrospectively reviewed to identify cases of EPH. During the study period, several measures aimed at preventing EPH were progressively implemented: reduction of primary and repeated caesarean, update of PPH treatment protocol, implementation of massive transfusion protocol, dedicated clinical pathway for high-risk patients, regular educational sessions, daily review of critical cases with senior consultant, and periodical review of near miss cases by quality improvement committee. To investigate the possible benefits, we divided the detected cases into two groups based on the historical period (Period I, 2012–2016 vs. Period II, 2017–2020) with the main aim of comparing the rate of EPH calculated as EPH ratio per 1000 deliveries. ResultsDuring Period I and II there were 30,241 and 21,270 births; a total of 60 and 25 EPH were performed, respectively. EPH incidence decreased from 2.0 to 1.2‰ across the study periods (p = 0.027). Between Period I and II, we observed a reduction of institutional caesarean section rate (44.4% vs. 40.4%, p < 0.0001); among cases undergoing EPH, we reported a significant reduction of massive blood transfusion (83.3% vs. 52.2%, p = 0.002), increased use (56.7% vs. 96.0%, p = 0.0004) and appropriate administration (25.0% vs. 88.0%, p < 0.0001) of tranexamic acid, increased use of non-invasive Bakri Balloon tamponade (3.3% vs. 32.0%, p = 0.0002) instead of surgical techniques (38.3% vs. 16.0%, p = 0.043). ConclusionA reduction of EPH incidence as a severe outcome of obstetric haemorrhage is achievable through a multilevel institutional effort. Our study may inspire a larger-scale program to improve the safety of patients experiencing PPH.

Risk Factors Analysis of Thoracic Trauma Complicated With Acute Respiratory Distress Syndrome and Observation of Curative Effect of Lung-Protective Ventilation.

PurposeTo explore the risk factors of acute respiratory distress syndrome (ARDS) secondary to thoracic trauma and the therapeutic effect of protective lung ventilation in patients with acute respiratory distress syndrome complicated with thoracic trauma.MethodsWe collected 206 patients with thoracic trauma admitted to our hospital from September 2017 to March 2021, counted the incidence of ARDS and analyzed the risk factors of ARDS. To observe the clinical efficacy of the application of lung-protective ventilation therapy in patients with thoracic trauma combined with ARDS.ResultsAmong 206 patients with thoracic trauma, there were 82 cases of combined ARDS, and its incidence was 39.81%. The 82 patients with ARDS were randomly divided into the control group and the observation group with 42 cases each, and different ventilation methods were used for treatment. The results showed that the mechanical ventilation time (MVT) was shorter in the observation group than in the control group, and the incidence of ventilator-associated lung injury (VALI) and case fatality rate (CFR) were lower than those in the control group (P < 0.05). Arterial partial pressure of oxygen (Pa02), arterial blood carbon dioxide partial pressure (PaCO2), and Oxygenation index (arterial partial pressure of oxygen/Fraction of inspiration O2, PaO2/FiO2) were significantly improved better in both groups after treatment; compared with the control group, patients in the observation group had higher Pa02 levels and lower PaCO2 levels at 8 h and 24 h after ventilation (P < 0.05). Multivariate analysis revealed that blunt trauma, massive blood transfusion, procalcitonin (PCT) level, tumor necrosis factor-α (TNF-α) level, and acute physiology and chronic health score (APACHE II) were all risk factors for Thoracic trauma with ARDS.ConclusionRisk factors for the development of ARDS after thoracic trauma are blunt injuries, massive blood transfusion, high PCT and TNF-α levels, and high APACHE II scores, which can be given active interventions in the early stage of clinical practice to improve patient prognosis. The use of protective lung ventilation therapy can improve the clinical outcome of patients with thoracic trauma combined with ARDS, which is important for improving the ventilation effect and respiratory function of patients.