Moderate Blood Loss Research Articles

Difficultés de la prise en charge de l’allo-immunisation anti-public

Alloimmunization against high-frequency erythrocyte antigens is a problematic situation in terms of laboratory diagnosis, transfusion and obstetrical management. We report the case of a pregnant woman alloimmunized against public Ag. We detail the difficulties of alloantibody (Ab) identification and transfusion management of the deliveries. A 29-year-old pregnant woman was hospitalized in gynecology and obstetrics departments at 36 weeks of gestation for assessment of hydrops fetalis. Antibody identification test revealed the presence of a pan-reactive antibody. Investigations realized in CNRGS (Paris) concluded in anti-GE2+anti-RH3+autoantibody. The red cell phenotype was GE: –2,3. A therapeutic interruption of the pregnancy was indicated. A program of autologous transfusion was organized with withdrawal of 2 units of blood. The 2nd pregnancy took place normally. Before delivery, an autologous blood reserve consisting of 2 red cell packs and 2 fresh frozen plasma was withdrawn and transfused after delivery. The management of anti-public alloimmunization poses several problems. The first one is of diagnostic nature with, on the one hand, the difficulty of Ab identification by the available red cell panels and, on the other hand, the possible presence of alloantibodies of transfusional or obstetric interest masked by anti-public Ab. The second is represented by transfusional care of these patients. In the absence of a national reserve of frozen rare blood, the autologous transfusion remains the only alternative. However, it can answer only a limited number of indications and only in case of moderate blood loss.

The geriatric polytrauma: Risk profile and prognostic factors.

In the German population, the percentage of elderly patients is increasing, and consequently there are more elderly patients among trauma cases, and particularly cases of polytrauma. The aim of this study was to present clinical results and a risk profile for geriatric polytrauma patients. Review of 140 geriatric (over 65 years of age) polytrauma patients who received prehospital treatment was performed. Severity of trauma was retrospectively assessed with Hannover Polytrauma Score (HPTS). Age, hemoglobin (Hb) level, systolic blood pressure (BP), Glasgow Coma Scale (GCS) score, timing of and necessity for intubation were analyzed in relation to mortality and in comparison with younger patients. Geriatric polytrauma patients (n=140) had overall mortality rate of 65%, whereas younger patients (n=1468) had mortality rate of 15.9%. Despite equivalent severity of injury (HPTS less age points) in geriatric and non-geriatric groups, mortality rate was 4 times higher in geriatric group. Major blood loss with Hb <8 g/dL was revealed to be 3 times more fatal than moderate or minor blood loss (Hb ≥8 g/dL). GCS score <12 corresponded to double mortality rate (39% vs 83%). Age by itself is significant risk factor and predictor of increased mortality in polytrauma patients. Additional risk factors include very low GCS score and systolic BP <80 mm Hg, for instance, as potential clinical indicators of massive bleeding and traumatic brain injury. Such parameters demand early and rapid treatment at prehospital stage and on admission.

Spleen trauma in children

The aim was to determine blood loss degree in case of spleen trauma in children and to justify safety of victims treatment without surgery. It was performed retrospective cohort study of 105 autopsies of children who died of combined trauma. 33 of them had spleen injury. Prospective cohort study was performed in 75 children with spleen injury, 69 (92%) from whom were treated without surgery. It was established that thanatogenetic feature of spleen injury in children is moderate blood loss (89.6% of victims), incidence of large and massive blood loss was 6.8% and 3.4% respectively. In unoperated children blood loss did not exceed 15% of blood volume. In group of operated children (n=6; 8%) incidence of large blood loss was 4% (n=3) and did not exceed 28% of blood volume. Prevalence of moderate blood loss in case of spleen trauma due to anatomic and physiological features and mechanisms of spleen injury is theoretically justified.

Simultaneous heart valve replacement surgery and abdominal subtotal hysterectomy: case report

A middle-aged woman with rheumatic heart disease, mitral valve prolapse and incompletely closed mitral valve medium, patent foramen ovale, merge multiple uterine fibroids, and moderate blood loss anemia underwent mitral valve replacement surgery with total abdominal hysterectomy under general anesthesia and cardiopulmonary bypass condition. The surgery was successful, and postoperative bleeding, blood clots, heart failure, and other related complications did not occur. Heart valve replacement surgery with the surgical treatment of uterine fibroids effectively improves the safety of surgical treatment for patients as well as reduces the patient’s medical expenses and risk of secondary surgery and trauma.

Coagulation competence and fluid recruitment after moderate blood loss in young men.

The coagulation system is activated by a reduction of the central blood volume during orthostatic stress and lower body negative pressure suggesting that also a blood loss enhances coagulation. During bleeding, however, the central blood volume is supported by fluid recruitment to the circulation and redistribution of the blood volume. In eight supine male volunteers (24 ± 3 years, blood volume of 6.9 ± 0.7 l; mean ± SD), 2 × 450 ml blood was withdrawn over ∼ 30 min while cardiovascular variables were monitored. Coagulation was evaluated by thrombelastography, and fluid recruitment was estimated by red blood cell count. Withdrawing 900 ml blood increased heart rate (62 ± 7 to 69 ± 13 bpm, P < 0.05; mean ± SD) and reduced stroke volume (113 ± 12 to 96 ± 14 ml, P < 0.05) leaving cardiac output, mean arterial pressure, and total peripheral resistance unchanged and, furthermore, reduced red blood cell count (4.80 ± 0.33 to 4.64 ± 0.37 × 10(12) cells l(-1), P < 0.05) indicating that 218 ± 173 ml fluid was recruited to the circulation. Withdrawing 450 ml blood reduced the time until initial fibrin formation (R: 6.5 ± 0.9 to 5.1 ± 1.0 min, P < 0.01), whereas the rate of clot formation increased after withdrawal of 900 ml blood (α-Angle: 66 ± 4 to 70 ± 3 deg, P < 0.01). Clot strength (maximal amplitude: 57 ± 4 mm), clot lysis 30 min after maximal amplitude (LY30: 0.8% [0-3.5%] (median [range])), and platelet count (218 ± 25 × 10(9) l(-1)) were unaffected. For supine males, ∼ 25% of a moderate blood loss is compensated by fluid recruitment to the circulation, which may explain the minor cardiovascular response. Yet, a blood loss of 450 ml accelerates coagulation, and this is further accentuated when blood loss is 900 ml.

"There is iron and iron…" Burkinabè women's perceptions of iron supplementation: a qualitative study.

Most pregnant women in Burkina Faso are iron deficient and many are anemic. This study assessed women's understanding of anemia and the role of iron in preventing and treating this condition. A qualitative study was conducted within a randomized controlled trial of weekly iron supplementation in a rural malaria endemic area. Focus groups with women of similar age, parity, and marital status took place in 12 of 24 study villages. Two additional focus groups were conducted with female field workers. Tape-recorded transcripts were translated into French and analyzed using Framework analysis. Anemia, for which no Mooré term or traditional treatment for anemia was evident, was described in terms of blood volume. Moderate blood loss (diminished blood) could be easily replaced by eating well and was not considered serious. Massive blood loss (finished blood) was a rare, life-threatening illness. Iron tablets could increase blood volume and help women withstand massive blood loss at delivery, but for the latter, transfusion was indicated. Women had no knowledge of iron's role and did not readily concede that iron supplements contained elemental iron. Neither adolescents nor field workers were convinced of the benefits of supplementing non-pregnant adolescents, who were incorrectly considered to be at low risk of anemia. Young women's knowledge of anemia did not provide an adequate explanatory framework to motivate anemia prevention. Improving information on the role of iron is especially important for adolescent girls who may be incorrectly considered at low risk of anemia as they have not yet experienced pregnancy.

Management of intraperitoneal hemorrhage bleeding as a complication of a gynecologic disease

Aim. To evaluate the effectiveness of intra- and post-surgical resuscitation targeted at blood loss replacement in patients with moderate, severe and profuse intraperitoneal hemorrhage caused by ectopic pregnancy and ovarian apoplexy. Methods. Heart rate variability and cardiac intervals assessment were used as additional criteria for patient monitoring. 97 female patients with intraperitoneal hemorrhage of 500-1500 ml underwent endoscopic surgery. Autologous blood transfusion, as well as packed blood products and blood substitutes were used for blood loss replacement. Heart rate variability assessment and analysis of cardiac intervals indicate that pathogenesis of adaptation and blood loss compensation in female patients with intraperitoneal hemorrhage exceeding 500 ml depends on blood loss volume and methods of blood loss replacement. Results. Parameters of adaptation and blood loss compensatory mechanisms in patients with moderate and severe blood loss, who underwent intrasurgical autologous blood transfusion, were close to normal values at days 7 and 14 after treatment. Patients with severe and profuse intraperitoneal hemorrhage treated with packed blood products had the longest red blood count and heart rate variability recovery period. Conclusion. Heart rate variability assessment allowed effectively estimating the treatment effect in female patients with intraperitoneal hemorrhage as a complication of a gynecologic disease exceeding 500 ml.

Posterior Transpedicular Dynamic Systems in the Treatment of Chronic Lumbar Instability

Dynamic stabilization is a new concept and a new technology in spinal stabilization. There are a lot of debates on this topic and most of the criticisms may be true; however, it should be kept in mind that every technology develops from necessity. If fusion could solve all the problems, scientists would not try to develop other solutions. Posterior dynamic stabilization is a hopeful technology and we believe that tremendous innovative surgical techniques and surgical instruments will develop in near future. We expect that we will open new horizons in your minds when you are considering treatment plans about your patients which need lumbar stabilization procedures. In this special issue, you will find several examples of dynamic stabilization surgeries for different spinal diseases. Clinical results were also given with expanded review of the relevant literature. The papers in this journal also open a new window about treatment of lumbar disc herniations. Type 2 and type 4 disc herniations, according to the Carragee classification, treated with dynamic stabilization instead of subtotal discectomy were discussed by A. F. Ozer et al. You will find manuscripts in this special issue regarding recurrent disc herniations, painful black discs, degenerative spondylolisthesis, and painful Modic degenerations with degenerative disc disease treated with posterior dynamic stabilization surgery. We believe that dynamic systems will be discussed more intensely in the treatment of degenerative disc and bony pathologies in the lumbar spine. There are a lot of biomechanical and clinical studies about dynamic stabilization systems of the lumbar spine. Recently, finite element studies also have been published frequently concerning these systems. D. U. Erbulut et al. have performed an excellent review on biomechanics of posterior dynamic stabilization systems, and readers will learn too much from this paper in this special issue. We know that load sharing of the spinal column is an important biomechanical factor which may directly affect a patient's pain level, fusion success, and future disease progression, following spine surgery. In this journal, there is also a well-written research about load-sharing and regional load distribution of the interbody area investigating comparisons with between rigid rods, semirigid PEEK rods, and semirigid dynamic posterior instrumentation with flexion-extension dampening materials. There is a very important paper about adult's degenerative scoliosis which concluded that pedicle screw-based dynamic stabilization can be used in elderly patients with mild degenerative lumbar scoliosis because this is a less invasive surgery with short operative duration, moderate blood loss, and low adverse event rates. Moreover, they also reported scoliosis curve stabilization, at an average followup of more than 5 years. It was believed that fusion is a gold standard for low back pain treatment so far. However, there have been several complications reported clinically. These complications mainly are related to pseudoarthrosis and adjacent segment degeneration due to high stiffness at the stabilized segment. As an alternative treatment, nonfusion stabilization systems became more and more popular in order to preserve mobility of a motion segment and eliminate adjacent segment phenomena. You will see research studies emphasizing the benefits of dynamic stabilization system to prevent pseudoarthrosis and adjacent segment disease in this issue. The posterior transpedicular dynamic stabilization method is a very good surgical procedure in the patients with segmental instability. When we consider the biomechanical problems including widening of neutral zone and weakness of parts which stabilize the spine, one can easily understand the effectiveness of dynamic systems in treating patients who have lumbar segmental instability. There are also reports about the benefits of interspinous spacers and the results in terms of pain control, motion preservation, and prevention of adjacent segment degeneration. The authors in this journal recommend its use in treatment as well as in prevention of adjacent segment disease specifically in young patients where spinal fusion for early degenerative disease is needed. We know that dynamic stabilization of the lumbar spine not only stops the degeneration process but also starts the regeneration. L.-Y. Fay et al. reported the rehydration of intervertebral disc after dynamic system surgery using MRI evaluation. These papers prove radiological improvement of the disc tissue after this surgery. Ali Fahir Ozer Vijay K. Goel Ahmet Alanay Mehdi Sasani Tunc Oktenoglu Deniz Erbulut

Late Bleeding after Total Thyroidectomy: Report of Two Cases occurring 13 Days after Operation

Postoperative hematoma is a rare but potentially life-threatening and unpredictable complication of thyroid surgery. We report two cases of very late postoperative bleeding occurring on the 13th postoperative day in patients treated with low-molecular-weight heparin and acenocoumarol. Patient 1 was readmitted with complaints of progressive anterior neck swelling and bleeding from the cervical wound without respiratory distress. The patient had restarted therapy with Acenocoumarol associated with Nadroparin one day before. Under general anesthesia, cervical exploration allowed detection of a superficial hematoma. Patient 2 returned to our institution with subhyoid ecchymosis and moderate blood loss from the left drainage wound. The patient underwent drainage and was treated conservatively. Although most bleeding occurs within 24 hours, caution should be taken in patients on oral anticoagulants and low-molecular weight heparin and close monitoring should also be advised at home after discharge, particularly if anticoagulant therapy has restarted.

A computational model of hemorrhage and dehydration suggests a pathophysiological mechanism: Starling-mediated protein trapping

We sought to understand the degree to which a single computational cardiovascular model could replicate the typical responses of healthy subjects through a breadth of blood loss patterns and whether such a model could illuminate the cause-effect relationships that underlie the observed responses. The model consisted of compartments for the upper body, lower body, viscera, and kidneys as well as a four-chambered heart and a pulmonary compartment. Transcapillary fluid flux was governed by Starling forces, whereas lymphatic flow was driven by hydrostatic tissue pressure and scaled by a lymphatic activation term. We adjusted parameters based on results from one protocol involving moderate continual blood loss in a canine model. Next, we simulated six additional protocols spanning euvolemic and dehydrated subjects and compared in silico behavior with in vivo hemodynamic responses and fluid shifts. The model was able to replicate group-averaged behavior (i.e., within 1 or 2 SEs) of the rate and quantity of vascular refill and the associated cardiac output during slow, moderate, and rapid ongoing blood losses, the restitution after the cessation of blood loss, and the absence of restitution in dehydrated subjects. The model suggested that the earlier phase of restitution, i.e., transcapillary fluid shifts, was antagonistic to the later phase of restitution, i.e., protein return via lymphatics. This phenomenon was termed "interstitial protein trapping." In conclusion, the model appears valid for a range of blood loss patterns and prehydration states. Further investigation into the in vivo relevance of interstitial protein trapping is justified.

Primary intracranial epithelioid hemangioendothelioma: a low-proliferation tumor exhibiting clinically malignant behavior

Epithelioid hemangioendothelioma is an extremely rare intracranial tumor and is regarded as a low-proliferation tumor. We present two cases of primary intracranial epithelioid hemangioendothelioma and give an overview of the English literature pertaining to this disease. We described two new cases of primary intracranial epithelioid hemangioendothelioma and performed a search of MEDLINE (PubMed) using the words "epithelioid hemangioendothelioma". Only cases in the English language that were intracranially located and contained clinical information pertinent to the analysis were included. The tumor in case 1 originated from the right temporal bone and invaded the surrounding cranium, dura and temple muscles. The tumor in case 2 was located in the petroclival bone and had also invaded the surrounding cranium. Both tumors were well vascularized. The tumors were totally (case 1) or subtotally (case 2) removed with moderate blood loss. A total of 36 cases of intracranial epithelioid hemangioendothelioma were found in the literature. The tumor was typically diagnosed in young adults and infants. There was no sex predominance in adult patients, while in children, males were more frequently affected (M/F ratio, 3.5:1). Surgical removal was the main therapeutic protocol, and adjuvant therapy included radiotherapy or chemotherapy. Including the 2 patients presented here, a total of 38 patients were analyzed: 32 % showed local invasion, 24 % suffered a recurrence, 15 % had metastases, and the mortality rate was 15 %. Intracranial epithelioid hemangioendothelioma is a rare, low-proliferation tumor, but it exhibits some clinically malignant behaviors, such as local invasion, recurrence and metastasis. Total resection is mandatory where possible, and radiotherapy and/or chemotherapy are otherwise required. Preoperative feeding-artery embolization is recommended.

Infusion-transfusion therapy in the treatment of patients with acute bleedings from the upper gastrointestinal tract

Aim. To improve the treatment outcomes of patients with acute bleedings from the upper gastrointestinal tract by improving methods of endoscopic hemostasis and prediction of disease recurrence. Methods. The results of treatment of 776 patients with bleedings from the upper gastrointestinal tract have been analyzed. Methods of conservative therapy, endoscopic hemostasis and surgical treatment were used in combination with infusion therapy. Results. Established was the necessity of a differentiated method of endoscopic hemostasis, depending on the localization of the bleeding source, its intensity and effectiveness during ongoing bleedings. Infusion therapy should be initiated from the moment of verification of the diagnosis of acute bleeding from the upper gastrointestinal tract, regardless of the degree of blood loss, and already in the hospital’s emergency department. In cases of mild bleedings the infusion volume is 800-1000 ml: 80% crystalloids + 20% of colloids. The volume of infusion in moderate blood loss is 1500-2300 ml: 60% crystalloids + 20 colloids % + 20% fresh frozen plasma. The volume of infusion in severe blood loss is 2700 ml and more: 20% of crystalloids + 30% colloids + 30% fresh frozen plasma + 20% erythrocyte mass. Replacement therapy requires careful monitoring of the hemodynamic parameters and infusion load due to the unpredictability of body reactions to blood loss and its replacement. In the absence of an effect of conservative treatment within 6-24 hours an emergency operation is indicated with the choice of an optimal method based on an assessment of the physiological status on a POSSUM scale of assessment. Conclusion. Implementation of substitution therapy, which correlates to the degree of blood loss, critically important in order to eliminate ischemia of the wall of the gastrointestinal tract and prevent recurrence of bleeding; the usage of new approaches to the prediction of recurrent bleedings and improvement of methods of endoscopic haemostasis reduces the frequency of their occurrence, duration of in-hospital stay of patients and postoperative mortality.

Surgical techniques of laparoscopic peritonectomy plus paraaortic lymph node dissection for the treatment of patients with positive lymph node metastasis and peritoneal seeding from rectosigmoid cancer

This multimedia article demonstrates the surgical techniques of laparoscopic pelvic peritonectomy plus aggressive lymph node dissection over the abdominal aorta and inferior vena cava for the treatment of rectosigmoid cancer. The surgical procedures are detailed in the attached video. This study enrolled 17 patients. All the patients successfully underwent surgery by the described surgical technique and had a zero conversion rate, an acceptable operation time (median 284 min, range 240-360 min), and moderate blood loss (median 294 ml, range 140-740 ml) through five small wounds (four 1-cm wounds for 5-12-mm abdominal ports and one 5-cm wound for tumor retrieval). The number of dissected lymph nodes was adequate (median 44, range 32-68). The operative complications represented 29.4% of all cases including anastomotic leakage in two cases, wound infection in two cases, and urinary retention followed by repeated urinary tract infection in one case. The patients had quick functional recovery, as evaluated by the length of the postoperative ileus (median 72 h, range 36-144 h), the hospital stay (median 14 days, range 12-28 days), and the degree of postoperative pain (visual analog scale median 4.0, range 3-6). Laparoscopic surgery can be performed safely for rectosigmoid cancer patients with pelvic peritoneal seeding and extensive abdominal paraaortic lymph node metastases requiring an extended abdomino-iliac lymphadenectomy plus curative pelvic peritonectomy.

The role of sympathetic nervous system in the development of neurogenic pulmonary edema in spinal cord-injured rats

The pronounced activation of sympathetic nervous system is a necessary prerequisite for the development of neurogenic pulmonary edema (NPE) in rats with balloon compression of spinal cord. In this study we examined whether this is a consequence of rapid activation of spinal pathways leading to sympathetic venoconstriction, blood pressure rise, and reflex bradycardia. We found that NPE development can be prevented by epidural upper thoracic anesthesia or by transection of the upper spinal cord. This indicates an important role of spinal pathways activation. NPE development can also be prevented by moderate blood loss, supporting the role of blood redistribution to pulmonary circulation. In rats developing NPE the catecholamine surge following spinal cord compression involved not only a dramatic increase of circulating norepinephrine but also of epinephrine levels. The pretreatment of rats with α-1 adrenoceptor blocker prazosin, α-2 adrenoceptor blocker yohimbine, or calcium channel blocker nifedipine prevented NPE development, whereas the effect of β-adrenoceptor blockade with propranolol was less convincing. In conclusion, considerable activation of thoracic spinal pathways, followed by marked catecholamine secretion, play a major role in the development of NPE in spinal cord-injured rats. Enhanced α-adrenergic nifedipine-sensitive vasoconstriction is responsible for observed blood pressure changes, subsequent baroreflex bradycardia, and blood volume redistribution, which represent major pathogenetic mechanisms of NPE development.

Blood loss after cesarean delivery: a registry-based study in Norway, 1999-2008

The objective of the study was to assess risk factors for moderate and severe blood loss after cesarean delivery (CD). All planned (n = 32,716) and emergency (n = 47,942) cesareans, as reported over a 10-year period to the Medical Birth Registry of Norway, were analyzed separately in a case-control design. Women with moderate (500 to ≤1500 mL) or severe (>1500 mL) blood loss were analyzed with women with blood loss less than 500 mL as controls in SPSS (version 17.0) with χ(2) test and logistic regression. The prevalence of severe blood loss was consistently higher in emergency (3.2%) than planned CD (1.9%). Planned and emergency CDs share common risk factors for both moderate and severe blood loss, whereas emergency CD carries in addition delivery-related risk factors. When revising management schemes for CD, anesthetic procedures should be reconsidered as surgical competence in cases with placenta previa, placental abruption, and low hemoglobin.

Validation of a haemoglobin dilution method for estimation of blood loss

Analysis of haemoglobin (Hb) dilution after bleeding is a simple, inexpensive and non-invasive method to estimate blood loss. Blood volume is estimated, taking sex, weight and height into account. The Hb concentration before and after blood loss is analysed and, from the difference, the blood loss volume can be calculated assuming a normovolemic subject. Although widely used this method has never been validated. The Hb concentration of 21 blood donors was analysed before and up to 4 days after a standard blood donation and in another 18 blood donors the Hb concentration was analysed before and on day 4, 6, 8, 11 and 14 after blood donation. The blood volume of each donor was calculated and the donated blood volume was estimated by weighing. We calculated the blood loss by the Hb dilution method and compared the calculated value with the donated blood volume. The mean donated blood volume was 442 +/- 10 ml, whereas the mean calculated blood loss was 152 +/- 214 ml using the Hb concentration of the first day after donation and 301 +/- 145 ml with the Hb concentration of day 6 after blood donation after which no further Hb decrease was observed. The directly measured Hb concentration was always higher than the calculated/expected Hb concentration based on the blood donation volume. The Hb dilution method underestimates the true blood loss by more than 30% after a moderate blood loss of approximately 10% of the total blood volume.

Feasibility of laparoscopic D3 lymphadenectomy for male rectosigmoid cancer with clinically positive lymph nodes

Laparoscopic D3 lymphadenectomy is a challenging surgical procedure and has not been reported before. The present study aimed to test the technical feasibility of this procedure. Fifty-four consecutive male patients with clinically staged III rectosigmoid cancer were recruited to undergo laparoscopic D3 lymph node dissection. The extent of the D3 lymphadenectomy of rectosigmoid cancer included skeletonization of bilateral common iliac arteries and veins and abdominal aorta upwards to the level of the duodenal third portion and left renal vein, in addition to the mesenteric dissection in the standard anterior resection. The patients were prospectively followed for surgical feasibility, efficiency, and outcomes. Laparoscopic D3 lymphadenectomy for rectosigmoid cancer was performed with acceptable operation time (303.4 +/- 35.8 min, mean +/- standard deviation) and moderate blood loss (344.8 +/- 50.6 ml) through small wounds. There was no mortality within 30 days after operation and the complication rate was acceptable (20.4%). The patients has quick functional recovery, as evaluated by the restoration of flatus passage (60.4 +/- 12.4 h), hospitalization (11.0 +/- 1.5 days), and the degree of postoperative pain (3.5 +/- 0.6, visual analogue scale). D3 lymphadenectomy resulted in the harvest of ample lymph nodes (24.6 +/- 4.5) for histopathological examinations and facilitated the upstaging of three (5.6%) patients. D3 lymph node dissection by the laparoscopic approach can be safely and efficiently performed for male rectosigmoid cancer with quick convalescence.

Présentation de cas : lésion pulmonaire aiguë associée à la transfusion (TRALI) — Un danger net et présent

To describe a case of transfusion-related acute lung injury (TRALI) after platelet transfusion immediately following cardiac surgery, and to review the clinical features, pathophysiology, management, and morbidity and mortality associated with such an event. A 62-yr-old man was transferred to our centre for urgent coronary artery bypass grafting in the setting of recent anti-platelet medication use. Soon after surgery he received platelet transfusions despite having only moderate blood loss. Shortly following the platelet transfusion, he suffered acute hypoxic and hypotensive decompensation requiring nitric oxide therapy, inotropic support, and prolonged need for mechanical ventilation. The patient was eventually discharged from the intensive care unit nine days following the event. The diagnosis of TRALI was made by clinical and radiographic criteria. Transfusion-related acute lung injury is now the leading cause of transfusion-related fatalities. Early diagnosis of TRALI is important and these reactions should be reported to the blood transfusion service so that appropriate action can be taken to prevent future morbidity and mortality in other patients. To reduce serious transfusion reactions, inappropriate transfusions must be minimized and the decision to transfuse blood products should be taken with care.

Change in pulse transit time and pre-ejection period during head-up tilt-induced progressive central hypovolaemia

Traditional vital signs such as heart rate (HR) and blood pressure (BP) are often regarded as insensitive markers of mild to moderate blood loss. The present study investigated the feasibility of using pulse transit time (PTT) to track variations in pre-ejection period (PEP) during progressive central hypovolaemia induced by head-up tilt and evaluated the potential of PTT as an early non-invasive indicator of blood loss. About 11 healthy subjects underwent graded head-up tilt from 0 to 80 degrees . PTT and PEP were computed from the simultaneous measurement of electrocardiogram (ECG), finger photoplethysmographic pulse oximetry waveform (PPG-POW) and thoracic impedance plethysmogram (IPG). The response of PTT and PEP to tilt was compared with that of interbeat heart interval (RR) and BP. Least-squares linear regression analysis was carried out on an intra-subject basis between PTT and PEP and between various physiological variables and sine of the tilt angle (which is associated with the decrease in central blood volume) and the correlation coefficients (r) were computed. During graded tilt, PEP and PTT were strongly correlated in 10 out of 11 subjects (median r = 0.964) and had strong positive linear correlations with sine of the tilt angle (median r = 0.966 and 0.938 respectively). At a mild hypovolaemic state (20-30 degrees ), there was a significant increase in PTT and PEP compared with baseline (0 degrees ) but without a significant change in RR and BP. Gradient analysis showed that PTT was more responsive to central volume loss than RR during mild hypovolaemia (0-20 degrees ) but not moderate hypovolaemia (50-80 degrees ). PTT may reflect variation in PEP and central blood volume, and is potentially useful for early detection of non-hypotensive progressive central hypovolaemia. Joint interpretation of PTT and RR trends or responses may help to characterize the extent of blood volume loss in critical care patients.

Oncologic Results of Laparoscopic D3 Lymphadenectomy for Male Sigmoid and Upper Rectal Cancer with Clinically Positive Lymph Nodes

Many Japanese surgeons routinely perform extended D3 lymph node dissection for the treatment of advanced rectosigmoid cancer with a view to achieving better tumor control. However, the application of a laparoscopic approach to perform D3 lymphadenectomy has been challenging. This phase 2 prospective study aimed to explore the oncologic results of this surgical approach. The study was conducted during a 6-year period, in consideration of median follow-up time being >3 years. The study subjects were tumor, node, metastasis system stage III rectosigmoid cancer staged by clinical images. The extent of D3 dissection and the postoperative lymph node mapping were according to the guidelines of the Japanese Society for Cancer of the Colon and Rectum. Patients were stratified according to the histopathologically proved highest level of involved lymph nodes and placed into N0, N1, N2, and N3 groups. The primary end points of the study were the estimated time to recurrence and 5-year recurrence rate of cancer after laparoscopic D3 dissection. The estimated 5-year recurrence rate (20% in the N0 group [n = 10]; 25% in N1 [n = 44]; 33.3% in N2 [n = 30]; and 42.8% in N3 [n = 14]), time to recurrence (mean [95% confidence interval] 59.8 [42.6-76.9] months in the N0 group; 56.8 [48.3-65.2] months in N1; 46.8 [37.5-56.1] months in N2; and 43.9 [28.3-59.4] months in N3), and recurrence patterns were without significant difference (all P values >.05) among N0, N1, N2, and N3 groups. Therefore, by laparoscopic wide anatomic dissection, patients with lymph node involvement could be treated as well as those without lymph node metastasis. Laparoscopic D3 dissection facilitated the collection of more lymph nodes (mean +/- standard deviation, 27.4 +/- 4.2) for histopathologic examination. Mapping of dissected lymph nodes showed that 18.2% (16 of 88) patients had skip lymph node metastasis. D3 dissection facilitated upstaging of cancer (from N0 to N3) in five patients (5.1%). However, this procedure resulted in transient voiding dysfunction in 77.5% patients and loss of ejaculatory function in 91.7%. By laparoscopic approach, the D3 lymph node dissection was safely performed through small wounds, resulting in quick functional recovery and only moderate blood loss (324.8 +/- 44.5 mL), but at the expense of a long operation time (294.4 +/- 34.8 minutes). The good short-term oncologic results and quick convalescence mean that the laparoscopic D3 dissection may be recommended for patients with stage III rectosigmoid cancer who could accept the genitourinary dysfunction.