Blood Product Replacement Research Articles

Ultrasound-guided versus palpation-guided techniques for vessel catheterization in children undergoing cardiac surgery. A systematic review and meta-analysis of randomized controlled trials

Abstract Background Pediatric heart surgery is the first treatment option for congenital heart disease, which is the leading cause of death in Children. Arterial cannulation (AC) and Central venous catheter (CVC) are required in pediatric cardiac surgery for continuous monitoring of the central venous pressure (CVP), replacement of fluid and blood products, close hemodynamic monitoring, and frequent sampling for arterial blood gases (ABG). Purpose We aim to assess the efficacy and safety of the ultra-sound guided technique compared to the traditional palpation-guided technique for vessel catheterization in children undergoing cardiac surgery. Methods A systematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs) studies obtained from PubMed, Embase Cochrane, Scopus, and WOS until February 2024. We used the fixed-effects model to report dichotomous outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD) with a 95% confidence interval (CI). Results Thirteen RCTs with 1060 children were included. Regarding arterial cannulation, ultrasound-guided technique was associated with a statistically significant increase in successful cannulation [RR: 1.31 with 95% CI (1.10, 1.56), P< 0.0001], and first-attempt success [RR: 1.88 with 95% CI (1.35, 2.63), P< 0.0001]; however, it was not associated with any statistically significant difference in venous cannulation in both outcomes with [RR: 1.13 with 95% CI (0.98, 1.30), P= 0.10], [RR: 1.53 with 95% CI (0.86, 2.71), P= 0.15] respectively. Moreover, ultrasound-guided technique was associated with a statistically significant decrease in the number of attempts either in arterial cannulation with [MD: -0.73 with 95% CI (-1.00, -0.46), P< 0.0001] or in venous cannulation with [MD: -1.34 with 95% CI (-2.55, -0.12), P= 0.03], and the time of attempted cannulation also either in arterial cannulation with [MD: -2.27 with 95% CI (-3.38, -1.16), P< 0.0001] or in venous cannulation with [MD: -4.13 with 95% CI (-7.06, -1.19), P< 0.0001]. Finally, ultrasound-guided technique was associated with a statistically significant decrease in the incidence of any complications either in arterial cannulation with [RR: 0.36 with 95% CI (0.18, 0.71), P< 0.001] or in venous cannulation with [RR: 0.30 with 95% CI (0.11, 0.84), P= 0.02]. Conclusion Ultrasound-guided arterial catheterization increases the number of successful catheterizations and first-attempt success rate; however, there was no significant difference in venous cannulation, while both arterial and venous cannulation were associated with decreased number of attempts, reduced overall procedure time, and decreased incidence of complications.

Management of von Willebrand Disease for Orthognathic Surgery: Evidenced-Based Recommendations and Scoping Review of the Literature

BackgroundThe general management of von Willebrand Disease has evolved over the past several decades. Advances in blood product replacement manufacturing have led to changes in perioperative management of the bleeding diathesis in its various subtypes. Surgical management follows changes in medical management, but unique perioperative considerations exist depending on the type of surgery. Orthognathic surgery is considered a major surgery that can have life-threatening complications in patients with von Willebrand Disease (vWD) and updates in evidenced-based management are presented. ObjectivesThe objectives of this report are to review available literature regarding management of patients with von Willebrand Disease and other bleeding disorder undergoing orthognathic surgery and to provide a case report regarding the management of a patient vWD type 2M undergoing orthognathic surgery. Eligibility CriteriaArticles included for review were studies addressing patients with bleeding disorders undergoing orthognathic surgery. Sources of EvidencePubMed and Ovid were queried using the terms “orthognathic surgery OR jaw deformity” AND “von Willebrand OR bleeding disorders OR hemophilia.” Additional references relevant to the review were obtained from the reference lists of available articles ultimately deemed appropriate for inclusion in the review. MethodsA recent example case of a patient with type 2M vWD undergoing orthognathic surgery and the patient’s perioperative management is presented for consideration. A scoping review of the literature was undertaken for evaluation of available literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR). ResultsInsufficient evidence exists for significant analysis of perioperative management strategies previously reported compared to the currently utilized management strategy for the case presented. A review of the available literature with reference to updated literature regarding management of patients with vWD undergoing surgical procedures other than orthognathic surgery yields primarily case reports, two randomized controlled trials, and one systematic review. The results indicate that an evolution in the general management of patients with vWD undergoing surgery can be applied to patients undergoing orthognathic surgery and that the addition of hemostatic agents such as tranexamic acid may be considered with a low level of evidence. ConclusionsFor patients undergoing orthognathic surgery, the use of cryoprecipitate in large quantities has been replaced with the use of Humate-P infusion and will likely be replaced with the use of recombinant von Willebrand factor (VWF). The timing of infusion of adjuncts preoperatively for patients with vWD can potentially be extended to the previous day, and the addition of medications to aid in hemostasis such as tranexamic acid may be considered. Prophylactic use of additional VWF adjuncts should be considered in the postoperative setting, and close monitoring is prudent. The use of newer agents may allow for the expansion of craniomaxillofacial surgery procedures that can be safely considered in patients with vWD.

Ultrasound-Guided Versus Palpation-Guided Techniques to Achieve Vascular Access in Children Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Pediatric heart surgery is a vital therapeutic option for congenital heart disease, which is one of the most prevalent causes of death in children. Arterial cannulation (AC) and central venous catheter (CVC) are required in pediatric cardiac surgery for continuous monitoring of the central venous pressure (CVP), replacement of fluid or blood products, close hemodynamic monitoring, and frequent sampling for arterial blood gases (ABG). A systematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs) retrieved from PubMed, Embase Cochrane, Scopus, and WOS until February 2024. Risk ratio (RR) was used to report dichotomous outcomes, and mean difference (MD) was used to report continuous outcomes, both with a 95% confidence interval (CI) using the random-effects model. Thirteen RCTs with 1060 children were included. Regarding arterial cannulation, the ultrasound-guided technique (US) was associated with a statistically significant increase in successful cannulation [RR: 1.31 with 95% CI (1.10, 1.56), P < 0.0001], and first-attempt success [RR: 1.88 with 95% CI (1.35, 2.63), P < 0.0001]. However, US was not associated with any statistically significant difference in venous cannulation in both outcomes with [RR: 1.13 with 95% CI (0.98, 1.30), P = 0.10], [RR: 1.53 with 95% CI (0.86, 2.71), P = 0.15] respectively. Moreover, US was associated with a statistically significant decrease in the number of attempts either in arterial cannulation with [MD: -0.73 with 95% CI (-1.00, -0.46), P < 0.0001] or in venous cannulation with [MD: -1.34 with 95% CI (-2.55, -0.12), P = 0.03], and the time of attempted cannulation also either in arterial cannulation with [MD: -2.27 with 95% CI (-3.38, -1.16), P < 0.0001] or in venous cannulation with [MD: -4.13 with 95% CI (-7.06, -1.19), P < 0.0001]. US guidance improves successful cannulation rates and first-attempt success in arterial access and reduces the number of attempts and procedural time for arterial and venous access. It was also associated with a lower incidence of complications and procedure failure, particularly in arterial access. However, it was associated with a higher incidence of venous puncture.

Circumferential correction of spinal deformity and instability secondary to bacterial spondylodiscitis

BackgroundSpinal deformity as a sequela of non-tuberculous spondylodiscitis is a rarely discussed clinical entity. Sagittal plane deformity, segmental instability, and persistently active infection overlap in these patients resulting in severe restriction in activity and quality of life. The presence of multiple medical co-morbidities restricts surgical options but nonoperative care may be ineffective and result in persistent, refractory discitis for years. We describe our experience with vertebrectomy and long-segment fixation for patients with post-infectious thoracic or lumbar deformity. MethodsA retrospective chart review of 23 consecutive patients who underwent vertebrectomy and long-segment fixation for thoracic or lumbar deformity secondary to nontuberculous bacterial spondylodiscitis was performed. Pre-, peri- and postoperative data is compiled and analyzed with a focus on the perioperative management algorithm to safely perform an extensive reconstruction in this very sick patient population. ResultsExtremely low preoperative quality of life was evident with 87% (20/23) of patients bedridden primarily due to pain despite 70% (16/23) of patients being strong enough to ambulate (Frankel D or E). Most patients (87%) already had an identified infection under adequate treatment either through blood cultures, prior biopsy or decompressive surgery. A single-stage posterior-only was the primary surgical approach utilized in the majority (83%) of cases. Complications were present in 100% of patients, most commonly perioperative anemia and hypotension requiring vasopressor support and aggressive blood product replacement. One in-hospital mortality occurred secondarily to pulmonary embolism. Mean preoperative segmental angle was 18±10 degrees of kyphosis which was corrected to 1±9 degrees of lordosis (p=0.001). The mean correction of the segmental angle was 19 degrees (standard deviation 23 degrees). Visual analogue scale scores improved from a pre-operative value of 8.8±0.9 to a post-operative value of 2.5±1.4 (p<0.001), which was obtained at the last outpatient follow-up (mean 631 days after surgery). Full self-care including ambulation was achieved in 18/23 (78%) patients, and the infection was successfully treated in 22/23 (96%) patients after long-term antibiotics. ConclusionsPatients with refractory spondylodiscitis on appropriate care and antibiotics are typically considered extremely poor surgical candidates despite non-operative care often being ineffective. Post-infectious deformity may also be so severe as to preclude a limited surgical treatment strategy. This study suggests that extensive circumferential reconstruction for deformity secondary to bacterial spondylodiscitis can be effective in restoring these extremely sick patients to self-care and ambulatory status.

Intra-Operative Hypotension is an Important Modifiable Risk Factor for Major Complications in Spinal Fusion Surgery.

Retrospective observational cohort. This study explores the impact of Intraoperative hypotension (IOH)on post-op complications for major thoracolumbar spine fusion procedures. IOH with mean arterial pressure (MAP) < 65mmHg is associated with post-op acute kidney injury (AKI) in general surgery. In spinal deformity surgery, IOH is a contributing factor to MEP changes and spinal cord dysfunction with deformity correction. 539 thoracolumbar fusion cases, > 6 surgical levels and > 3 hours duration were identified. Anesthetic/surgical data included OR time, fluid volume, blood loss, blood product replacement and use of vasopressors. Arterial-line based MAP data was collected at 1 min intervals. Cummulative duration of MAP < 65mmHg was recorded. IOH within the first hour of surgery vs. the entire case was determined. Post-op course and complications including SSI, GI complications, pulmonary complications, MI, DVT, PE, AKI and encephalopathy were noted. Cumulative complications were grouped as none, 1-2 complications, or >3 complications. There was a significant association between occurrence of complications and duration of IOH within the first hour of surgery (8.2 vs. 5.6 min, P<0.001) and across the entire procedure (28.1 vs. 19.3 min, P=0.008). This association persisted for individual major complications including SSI, acute respiratory failure, PE, ileus requiring NGT and post-operative cognitive dysfunction. Comparison of patients with 0 vs. 1-2 vs. 3 or more complications demonstrated that patients with 3 or more complications had a longer duration of IOH in the first hour of the surgery and that patients who had no complications received less vasopressor than patients who had 1-2 or 3 or more complications. This study identifies duration of IOH during the first hour of surgery as a previously unrecognized modifiable risk associated with major complications for multi-level lumbar fusion surgery.

Evaluation of the effect of parenteral nutrition on mortality and morbidity in hospitalized patients with non-variceal upper gastrointestinal bleeding

Objective: Nutritional support products should preferably be administered orally whenever possible, with rare exceptions, one of which is gastrointestinal bleeding. In our study, we examined the effects of parenteral nutrition support, which we have recently introduced in the treatment of patients with gastrointestinal bleeding, on the hospitalization duration and mortality-morbidity of these patients. Methods: We analyzed the patients admitted to the Internal Medicine Service with non-variceal upper gastrointestinal bleeding in our study. Patients were retrospectively analyzed in two groups, based on the years in which total parenteral nutrition (TPN) was initiated (2016-2017) and not initiated (2012-2013). Hospitalization durations and discharge methods were compared between the two groups. Results: Our study included a total of 369 cases after screening and application of our exclusion criteria. 35.5% of these cases received TPN, while 64.5% did not. When evaluated based on the TPN administration status after stabilizing the Rockall score of the patients, as well as considering the need for erythrocyte suspension (ES), fresh frozen plasma (FFP) replacement, and length of hospital stay, the length of hospital stay was significantly longer in those receiving TPN compared to those who did not. Conclusion: Although TPN may be the preferred choice in patients with upper gastrointestinal bleeding for whom oral nutrition is not suitable, our study suggests that this preference not only does not lead to a reduction in the number of blood and blood product replacements but also prolongs the hospital stay. While it is believed that complications of nutritional support with TPN may contribute to this result, our retrospective study did not provide data on this. Comprehensive prospective studies are needed on this issue.

Endovascular Repair of Ruptured Aortic Aneurysm: A Single-Center Experience.

Aortic rupture is a rare and catastrophic emergency. Prompt diagnosis and treatment are the primary determinants of mortality. During follow-up, the majority of patients who have been effectively treated die from hypovolemic shock and multiorgan failure. This article describes the clinical and procedural details of sixteen patients with ruptured aortic aneurysms treated endovascularly. In addition, it discusses the main factors contributing to the mortality of these patients. Patients who underwent endovascular treatment for acute aortic rupture at our center from October 2016 to March 2023 were included in this retrospective study. A total of 16 patients underwent endovascular aneurysm repair (EVAR) or thoracic endovascular aneurysm repair (TEVAR) for acute aortic rupture. The patients' mean age was 73.06 years (range: 52-92), and 15 of them were male. The ruptures occurred in the abdominal aortic aneurysm in ten patients, in thoracic aortic aneurysm in three patients, in the isolated iliac artery aneurysm in two patients, and there was one case of non-aneurysmal aortic rupture. In our series, patients who presented with an impending, self-limited rupture and stable hemodynamic status had good prognostic outcomes. However, eight patients died due to multiorgan failure, hemorrhagic shock, disseminated intravascular coagulopathy, renal failure, or abdominal compartment syndrome. These patients generally had poor admission vital signs and low hemoglobin values. The most critical determinants for the success of the procedure are promptly stopping the bleeding, avoiding general anesthesia, and opting for blood product replacement instead of fluid replacement. Each patient with ruptured aortic aneurysm should be managed according to the patient's hemodynamics at presentation, the size of the aneurysm, the suitability for percutaneous procedure, logistical factors, and the operator-center's experience.

Evaluation of epidemiological, clinical, laboratory and treatment characteristics of Crimen Congo hemorrhagic fever patients: Results of a 10-year analysis.

Crimean-Congo hemorrhagic fever (CCHF) is a viral zoonosis transmitted by ticks and may have an acute and severe course with fever, bleeding, muscle aches, headache, diarrhea, weakness, and similar non-specific symptoms. This study aimed to determine the distribution of CCHF cases in Amasya province, which is endemic for this disease, according to districts, epidemiological, clinical, laboratory, and treatment characteristics. The characteristics of 88 CCHF cases over 18 who were admitted to our clinic and treated between January 2013 and January 2023 were evaluated retrospectively. Demographic data such as age, gender, occupation, district of residence, history of tick contact, the incubation period of the disease, period of development of the disease (months, years), length of hospital stay, symptoms, physical examination and laboratory findings, blood product replacement therapies applied, recovery and mortality status of the patients were reached by scanning the patient files. The mean age (±standard deviation) of 88 cases was 48±18 years, and 53 (60.2%) were male. Of the patients, 68 (77.3%) were engaged in farming and animal husbandry, and 79 (89.7%) lived in villages and hamlets. Tasova district had the highest frequency of cases, with 29 (32.9%) patients. June was the most common month for the disease, with 31 (35.2%) cases. The most common symptom on admission was fatigue, with a rate of 93%. Other symptoms included myalgia and arthralgia (83.2%), fever (65%), headache (64.4%), nausea-vomiting (43.5%), conjunctival hyperemia (35.2%), and diarrhea (21.7%). In clinical follow-up, bleeding was missed in 15 (17.04%) patients. On admission to the hospital, there were elevated levels of thrombocytopenia (92%), leukopenia (84.1%), aspartate aminotransferase and alanine aminotransferase (86.3%), creatinine phosphokinase (71.6%), and lactate dehydrogenase (76.1%). None of the patients were given ribavirin treatment. Our mortality rate was 3.40% with three patients. Amasya is an endemic area for CCHF with all its districts. In our province's spring and summer months, tick contact history and the farming-livestock profession should be questioned in patients with fever complaints in clinic admissions, especially emergency services. In the case of the detection of thrombocytopenia in these patients, CCHF should be kept in mind.

Utility of rotational thromboelastometry in the management of massive haemorrhage at a regional Australian hospital.

Rotational thromboelastometry (ROTEM) allows targeted and individualised blood product replacement. The study aimed to determine the impact of ROTEM-guided transfusion on the clinical course of patients with acute massive haemorrhage in a regional Australian hospital. A retrospective review of all patients with acute massive haemorrhage that compared the characteristics, blood product use, and clinical outcomes of patients with massive haemorrhage before and after the introduction of ROTEM-guided transfusion. In per-protocol analysis, the 31/97 (32%) with ROTEM-guided transfusion used less packed red blood cells (median [interquartile range]: 6 [6-8] vs. 8 [6-12] units, p = 0.03) than patients whose transfusion was not ROTEM-guided. They were also less likely to receive fresh frozen plasma (2/31 [6%] vs. 45/66 [68%], p < 0.0001) or platelets (2/31 [6%] vs. 31/66 [47%], p < 0.0001); they were, however, more likely to receive fibrinogen products (26/31 [84%] vs. 38/66 [58%], p = 0.01). Patients receiving ROTEM-guided transfusion had lower in-hospital mortality (6/31 [19%] vs. 20/66 [30%], odds ratio 0.55 [95% confidence interval]: 0.20-1.55, p = 0.26) although this did not achieve statistical significance in this small cohort. ROTEM-guided massive transfusion of patients with acute haemorrhage in this regional Australian hospital led to a reduction in packed red blood cell, fresh frozen plasma, and platelet utilisation and may also have reduced mortality.

Exploration of rotational thromboelastometry (ROTEM) to characterize the coagulation profiles of newly diagnosed pediatric leukemia patients

BackgroundViscoelastic testing has been used in adult hematologic malignancies in conjunction with conventional coagulation tests (CCTs) to predict coagulopathies and tailor blood product replacement. However, there is a paucity of similar pediatric studies. ObjectivesAnalyze and correlate leukemia-associated coagulopathy in newly diagnosed pediatric leukemia patients using CCT’s and Rotational Thromboelastometry (ROTEM). MethodsPediatric patients with newly diagnosed acute leukemia underwent testing with ROTEM and CCTs on days 0, 15 and 29 of induction chemotherapy. ResultsSixty-two patients were enrolled. At presentation, 54.8 % of patients had platelets <50 K/μL, 73 % had prolonged PT, 1.6 % had fibrinogen <150 mg/dL. Fifteen patients (24.2 %) had WHO grade 1 bleeding and two patients (3 %) had WHO grade 4 bleeding. EXTEM/INTEM values at presentation (day 0) reflected hypocoagulability, however FIBTEM revealed hypercoagulability. Patients showed a progressive hypocoagulability in all ROTEM assays by day 15 (day 0 vs day 15, p < 0.001), with improvement by day 29 (day 15 vs day 29, p < 0.001). Day 0 ROTEM parameters were comparable to day 29. Fibrinogen strongly correlated with ROTEM at all three time points (p < 0.0001), along with platelet count with moderate correlations (p < 0.001). ConclusionFibrinogen and platelets appear to be the drivers of leukemia associated coagulopathy in the pediatric population, suggesting the utility of using CCTs and ROTEM in this population to better evaluate hemostatic function and guide blood product replacement.

Comparison of ultrafast and fast track extubation after secundum atrial septal defect surgery in pediatric age group

Bacground Patients who underwent ultrafast track on the operating table and fast track extubation in the pediatric intensive care unit for 2 to 6 h after secundum atrial septal defect surgery in the pediatric age group were compared. Methods Between January 2013 and February 2017, 60 pediatric patients (24 boys, 36 girls; Mean age 7.5 ± 4.6 years) whose secundum atrial defect was closed were retrospectively analyzed. The patients were separated as those who were extubated on the operating table (Group1,n = 28) and those extubated in the pediatric intensive care unit within 2-6 h postoperatively (Group2,n = 32). Results No difference was found in demographic data and preoperative catheter information between the groups. Cardiopulmonary bypass time was 20(18–25)/27.5(20–30)minutes (p:0.001), the cross-clamp time was 10(10–15)/15(11–20)minutes(p:0.004), the postoperative drainage amount was 50(25-50)/60(32.5–100)ml(p:0.013), the length of stay in the intensive care unit was 1(1-–1)/1(1–2)day(p:0.025), the length of stay after intensive care was 3(2–3)/3(3–4)days(p:0.001) and the total hospital stay was 4(3–4)/5(4–5.5) days (p < 0.001), which were respectively shorter for the group 1 compared to 2. Postoperative blood product replacement, positive inotrope support, pericardial effusion, mortality, and morbidity were not detected in either groups. Conclusion In this study, it was observed that the UFT extubation was safe for the patients who were operated for secundum ASD, in the pediatric age group, and had a cross-clamp time not exceeding 15 min. It was found that the amount of drainage, length of stay in the intensive care unit, post-intensive care unit, and the total hospital stay of patients extubated on the operating table were shorter.

The implications of antithrombotic agents on subdural hematoma evacuation: what does "reversal" truly entail?

The optimal perioperative management of antithrombotic therapy (ATT) in patients requiring urgent neurosurgical intervention for subdural hematoma (SDH) is poorly understood. The delicate equilibrium of effective hemostasis while preventing thrombosis is complex and relies on numerous factors such as indication for and type of ATT, medical comorbidities, and extent of neurological injury. This study aimed to analyze the impact of ATT and reversal strategies on surgical outcomes to highlight current challenges in the management of these high-risk patients. The authors performed a retrospective surgical cohort analysis of 100 patients undergoing urgent SDH evacuation at a level I trauma center between March 2020 and May 2021. The patients were first stratified into two cohorts based on preoperative ATT use and then further segregated by receipt of reversal agents. Statistical analysis included the chi-square test, Welch two-sample t-test, and multivariate logistic regression. The primary outcome was mortality. Secondary endpoints included radiographic SDH reexpansion, revision surgery, improvement in preoperative neurological deficits, and incidence of thromboembolism. A crossover cohort was secondarily analyzed in patients for whom ATT was interrupted for a minimum duration equal to effective drug metabolism. Finally, ATT reinitiation patterns were examined. Of 100 patients, 48% received ATT, 54.2% of whom were given reversal agents. ATT use was significantly associated with decreased rates of postoperative neurological improvement (p = 0.023) with trends toward increased mortality (p = 0.078), SDH reexpansion (p = 0.12), and need for revision surgery (p = 0.10). Patient crossover revealed a 4 times greater likelihood of death in patients without ATT interruption prior to surgery (p = 0.040) without an observable impact on secondary outcomes. ATT reversal contributed no improvement in outcomes other than a decreased intensive care unit length of stay when adjusted for in-hospital mortality (p = 0.014). The rate of postoperative thromboembolism following ATT reversal was 11.5%. ATT reinitiation was highly variable, occurring in 59.5% of patients, with median times of 17 and 15 days for antiplatelets and anticoagulants, respectively. Use of preoperative ATT portends poor clinical outcomes following nonelective SDH evacuation regardless of attempts to reverse these medications with replacement blood products. This study further reinforces the critical need for judicious use of ATT and optimization of reversal strategies in high-risk patient populations as best guided by multidisciplinary teams and evolving clinical practice guidelines.

Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage.

Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.

Managing the coagulopathy of postpartum hemorrhage: an evolving role for viscoelastic hemostatic assays

Postpartum hemorrhage (PPH) is usually caused by obstetrical complications but may be exacerbated by hemostatic impairment. Standard laboratory tests of coagulation often take too long to become available to inform treatment in a rapidly changing clinical situation. The role of point-of-care viscoelastic hemostatic assays (VHAs) in monitoring hemostatic impairment and guiding procoagulant blood product replacement during PPH is evolving, although these technologies are not available in most maternity units. We have used VHAs during PPH in our institution for the last 8 years and have developed a simple algorithm to direct blood component replacement. VHAs are useful for reassuring clinicians that hemostasis is adequate and that procoagulant blood products are not required and an obstetrical cause for bleeding needs to be sought. VHAs can be used to detect hypofibrinogenemia due to dilution or acute obstetrical coagulopathy and to guide fibrinogen replacement. The role of VHAs in guiding fresh frozen plasma infusion is less clear, but normal results suggest that fresh frozen plasma is not required. In this review, we describe 3 cases of postpartum hemorrhage to illustrate different hemostatic scenarios and discuss the controversies and evidence gaps related to each case.

Prolonged prothrombin time does not correlate with clinical bleeding symptoms in newly diagnosed paediatric leukaemia patients.

Prolonged prothrombin time (PT) and/or activated partial thromboplastin time (aPTT) are frequently seen in newly diagnosed paediatric leukaemia patients (NDPLP), which can lead to delayed diagnostic and therapeutic procedures due to concern for bleeding. A single-centre retrospective chart review of NDPLP between 2015 and 2018 aged 1-21 years. We analysed 93 NDPLP of whom 33.3% had bleeding symptoms within 30 days of presentation, predominantly mucosal bleeding (80.6%) and petechiae (64.5%). Median laboratory values: white blood cell count 15.7, haemoglobin 8.1, platelets 64, PT 13.2 and a PTT 31. Red blood cells were administered in 41.2%, platelets in 52.9%, fresh frozen plasma in 7.8% and vitamin K in 21.6% of patients. Prolonged PT was found in 54.8% of patients, while aPTT was prolonged in 5.4%. Anaemia and thrombocytopenia did not correlate with prolonged PT (P = 0.73 and P = 0.18, respectively), or prolonged aPTT (P = 0.52 and 0.42). Leukocytosis showed significant correlation with elevated PT (P < 0.001), but not aPTT (P = 0.3). Bleeding symptoms upon presentation did not correlate with prolonged PT (P = 0.83), prolonged aPTT (P = 1) or anaemia (P = 0.06) but had a significant correlation with thrombocytopenia (P ≤ 0.0001). Therefore, a prolonged PT in NDPLP may not necessitate the reflexive use of blood product replacement, in the absence of significant bleeding, which is likely related to leukocytosis than to a true coagulopathy.

CAUSES OF EXCESSIVE BLEEDING IN PATIENTS UNDERGONE OPEN HEART SURGERY DURING EARLY POSTOPERATIVE PERIOD; OUR EXPERİENCES FOR TWO YEARS

<h3>Objective</h3> The rate of excessive bleeding during open-heart surgery is 10 %. The rate of re-exploration is about 4-6 %. Therefore, it makes the mortality and morbidity increase after surgery The aim of our study is to identify the incidence of excessive bleeding and its causes during the early postoperative phases in patients undergone open-heart surgery in our institution for two years respectively. <h3>Design and Method</h3> It reviewed the hospital database to identify patients who underwent elective open-heart surgery between Jan.2019 and Jan.2021. It was defined as excessive bleeding involved measuring the amount of hemorrhage during the 1st, 2nd, 3rd, and 24th hours. We divided the cases into two groups, Group Bleeding; Group B; if excessive bleeding was present, and Group Control; Group C; if it was not. Data on demographics, clamping and pumping times in the operating room, intraoperative interventions, and clinical data such as the need for blood and blood products replacement in the ICU were recorded in the case files. Data were analyzed Student's t, Mann Witney U, Pearson Chi-Square Tests and Correlations tests. p<0.05 is statically significant. <h3>Results</h3> The incidence of bleeding was 9.7%. The rate of re-exploration was 33%. The presence of chronic lung disease was significantly higher in the bleeding group (Group B) (p=0.006). Preoperative use of anti-aggregates and diuretics was significantly higher in Group B than in Group C (p=0.00 and p=0.02, respectively). There was no significant difference between the groups in terms of bleeding and coagulation laboratory values and the use of intraoperative blood and blood products (Table 1). Postoperative use of blood and blood products was significantly higher in Group B (p<0.001, Table 2). Negative correlation between the female gender and higher EF and bleeding (p=0.032, p=0.047, respectively). A positive correlation was found between chronic lung disease, presence of CRF, diuretic, anticoagulant, EuroScore level, duration of ECD, and duration of CC and bleeding. The incidence of anemia among all patients was found at 41 % <h3>Conclusion</h3> Patients undergoing open-heart surgery under elective conditions had a 9.7% occurrence of excess bleeding and the rate of re-exploration was 33% in the early postoperative period. The presence of chronic lung disease, use of anti-aggregates and diuretics prior to surgery, a low EF score and high EuroScore, and the duration of the patient's CC and ECD were all highly predictive of excessive bleeding. In a conclusion, we thought that to improve the anemia, stopping the anti-aggregates drugs convenient time and having optimum control of the chronic diseases during preoperative evaluation might be effective for preventing excessive bleeding during the perioperative period.

Point-of-care coagulation testing for postpartum haemorrhage.

The use of viscoelastic haemostatic assays (VHAs) to guide blood product replacement during postpartum haemorrhage is expanding. Rotem and TEG devices can be used to detect and treat clinically significant hypofibrinogenaemia, although evidence to support the role of VHAs for guiding fresh frozen plasma and platelet transfusion is less clear. If Rotem/TEG traces are normal, clinicians should investigate for another cause of bleeding, and haemostatic support is not required. Guidelines support the use of VHAs during postpartum haemorrhage as part of locally agreed algorithms. There is a wide consensus that fibrinogen replacement is needed if the Fibtem A5 is <12 mm and if there is ongoing bleeding. Guidelines recommend against using VHAs to guide tranexamic acid infusion, and this drug should be given as soon as bleeding is recognised, irrespective of the Rotem/TEG traces. The cost-effectiveness of VHAs during postpartum haemorrhage needs to be addressed.

Blood Product Replacement for Postpartum Hemorrhage.

Consideration for blood products replacement in postpartum hemorrhage should be given when blood loss exceeds 1.5L or when an estimated 25% of blood has been lost. In cases of massive hemorrhage, standardized transfusion protocols have been shown to improve maternal morbidity and mortality. Most protocols recommend a balanced transfusion involving a 1:1:1 ratio of packed red blood cells, platelets, and fresh frozen plasma. Alternatives such as cryoprecipitate, fibrinogen concentrate, and prothrombin complex concentrates can be used in select clinical situations. Although transfusion of blood products can be lifesaving, it does have associated risks.

Intraoperative management of coagulation disturbances, replacement of blood, blood products and fluid management during living donor liver transplantation

Bayalagmaa Khuvtsagaan, Bazarragchaa Regjii, Chuluunbaatar Donkhim, Enkh-Amgalan Dorjbal, Odontuya Sanjaadorj, Tsiyenpiljee Amgaa, Ganbold Lundeg. Korean J Transplant 2022;36:194. https://doi.org/10.4285/ATW2022.F-3279

First Massive Transfusion Protocol (MTP) Implementation Proposal in Egypt

Abstract Introduction/Objective Massive transfusion is often defined as transfusion of adults with 10 or more of packed red blood cells units in 24 hours period or transfusion of 4 or more units of packed red blood cells (PRBCs) in one hour when on-going need for more transfusion is foreseeable. Massive transfusion protocol in children is defined as transfusion of &amp;gt;40 mL/kg. Massive transfusion protocol (MTP) is a vital element of damage control resuscitation and provides a coordinated clinical response to hemorrhage in patients requiring massive blood transfusions after hospital admission. Hemorrhage is the most common cause of death within the first hour of arrival to the trauma center. Methods/Case Report This study aims to develop and establish the first massive protocol in Egypt to provide a consistent treatment for blood transfusion for trauma patients that will Reduce delay in ordering and administering blood products and Deliver a reasonable ratio of plasma to red blood cells. The protocol will be first implemented in a military hospital in Egypt. Developing the massive transfusion protocol will allow the practitioners to follow algorithm for rapid replacement of blood products using uncrossmatched packed red blood cells, Plasma, platelets and cryoprecipitate if necessary. Adopting the American Association of Blood Banks (AABB) and the American College of Surgeons (ACS) guidelines are the best practice around the world. The Protocol will be developed by multidisciplinary committee engagement, Blood bank, Diagnostic laboratory and Clinical care areas (OR, ER, ICU, OBS). Results (if a Case Study enter NA) The massive transfusion protocol ratio will be 3:2 (RBC: FFP) and one units of platelets for every 6 units of RBC. according to American College of Surgeons (ACS) guidelines the ratio should be 1:1 to 1:2 (RBC: FFP). The committee established defined criteria for MTP activation and termination. The delivery time of the blood products should be between 5-10 minutes. Administration of tranexamic acid to inhibit plasminogen activation and stabilize the clot. Conclusion The Developing and Implementing MTP in Egypt will provide reduction in mortality for trauma and uncontrolled hemorrhage patients. Once implemented, we will regularly evaluate the use and efficacy of the MTP to ensure positive patient outcomes., the MTP will be evaluated to ensure best practice.