Blood Product Replacement Research Articles

Does Preoperative Beta-blocker Use Influence Intraoperative Hemodynamic Profile and Post-operative Course of Liver Transplantation?

ObjectiveWe compared the intraoperative hemodynamic profiles and outcomes of liver transplant (LT) patients receiving preoperative beta-blockers for portal hypertension with those of patients not receiving beta-blockers. MethodsBeat-to-beat hemodynamic data were recorded with the use of a lithium dilution cardiac output monitor, including heart rate (HR), cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVR), SVR index, mean arterial pressure, stroke volume (SV), and SV index. Perioperative data included age, sex, etiology of cirrhosis, Model of End-Stage Liver Disease score, warm and cold ischemia times, and intraoperative blood and blood products replacement. Postoperative data included Acute Physiology and Chronic Health Evaluation II score, Intensive Care National Audit and Research Centre (ICNARC) score, length of intensive care unit stay, renal replacement treatment, and mortality. ResultsAfter exclusion, 215 patients not receiving and 93 patients receiving beta-blockers for portal hypertension were included. There was no significant difference between groups in demographic data. HR, CO, and CI were significantly lower in the beta-blocker group (P = .0001). Regarding outcomes, the ICNARC score was significantly higher in the beta-blocker group (P < .05). ConclusionsPreoperative administration of beta-blockers attenuates the hyperdynamic circulation in LT patients; this is clearly seen through a reduction in intraoperative CO, CI, and HR. This decreased hyperdynamic state was not shown to relate to outcomes in any of the variables except for a higher ICNARC score reported in the group treated with beta-blockers.

Coagulopathy in Acute Promyelocytic Leukemia: Strategies to Improve Assessment of Hemostatic Risk

In patients with acute promyelocytic leukemia (APL), in spite of recent advances, early treatment related mortality (TRM) still remains a challenge and is largely related to the associated coagulopathy. It is well recognized that conventional coagulation parameters used in the clinic do not accurately predict the risk of adverse outcomes like major bleeding or thrombosis. There is limited data on the clinical utility of whole blood viscoelastic assays and extended coagulation parameters for evaluation of coagulopathy in patients with APL.Consecutive patients with PML-RARA positive APL were enrolled. Blood samples were collected prior to infusion of blood products on day 1 and again on day 4 for thromboelastometry done on whole blood and activated with recombinant tissue factor at a final dilution of 1:50,000 (ROTEM analyzer, Tem Innovations GmbH, Basel) and an extended panel of coagulation parameters done by immunoassays (TAT complex, protein C, ATIII, PIC complex, tPAIC, d-dimer and thrombomodulin). Platelet count and conventional coagulation parameters, which were prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and thrombin time (TT), were measured daily for the first 14 days (more frequently as clinically indicated). Patients received platelet transfusions to target a platelet count of 30x109/L (in the absence of bleeding). Fresh frozen plasma and cryoprecipitate transfusions were done to target a normal PT and aPTT and maintain a fibrinogen level above 140 mg%. Major bleeding, thrombosis and death during induction therapy were the outcome variables.Of the 61 patients enrolled, 11 were excluded (3 did not continue treatment at our hospital, 2 died within 48 hours of admission, and 6 took discharge against medical advice before completing induction). Of the remaining 50 cases that were evaluated, 40 were newly diagnosed and 10 were relapsed. The median age was 34.5 years (range 9-68). 25 were males (50 %). The WBC count was above 10 x 109/L in 20 patients (40%). The median platelet count was 28 x 109/L (range 4-339). There were 13 (26%) deaths in induction. Six patients had a major bleeding event. Five patients had a thrombotic event. Of the evaluated conventional coagulation parameters, extended coagulation parameters, platelet counts and ROTEM parameters at diagnosis (ROTEM data not available at diagnosis in 2 cases) only the ROTEM parameter of maximum clot firmness (MCF) as a continuous variable was significantly associated with death (p=0.012). On univariate cox regression analysis with death as the outcome, MCF≤ 30mm was a poor prognostic marker (hazard ratio of 13.24, 95%CI 1.71-102.19; p =0.013). On multivariate cox regression analysis including high WBC count (>10 x 109/L), low platelet count (< 40 x 109/L) and history of relapse, MCF ≤30mm was an independent poor prognostic variable (HR: 11.89; 95% CI 1.43 - 98.75; p 0.022). Four of the 6 major bleeding events, four of five thrombotic events and all deaths related to coagulopathy occurred in patients with MCF ≤30mm. The descriptive statistics of patients with MCF >30mm (n=21) vs those with MCF ≤ 30mm (n=27) are shown in table 1. Figure 1 illustrates the type of discordance one can see between conventional coagulation parameters and ROTEM values.This study suggests that the MCF value from a ROTEM assay at diagnosis is probably a better measure of the hemostatic defect at diagnosis in APL. Patients with APL with low MCF on ROTEM at diagnosis are at an increased risk of death during induction therapy despite an adequate blood product replacement strategy which was based on conventional coagulation parameters. In these patients, there is a need to develop novel and possibly a more intensive replacement strategy.Table 1Comparison of baseline characteristics and clinical outcomes.VariablesMCF ≤30 (n = 27)N (%) /Median (range) / Mean±SDMCF > 30 (n=21)N (%) /Median (range) / Mean±SDp valueAge (years)40(12-68)27(9-48)0.006WBC >10 x x109/L17(62.96)2(9.52)0.003Platelet count (x109/L)17(4-89)45(10-339)0.001PT in seconds14.5(11-87.5)11.8(10.1-14.8)0.004aPTT in seconds28(23.2-77.9)30.2(22-53.6)0.104Fibrinogen in mg%134.8(24.7-393)172.2(14.7-549.5)0.066Major bleeding4(14.8)1(4.8)0.368Thrombosis4(14.8)1(4.8)0.369Death12(44.4)1(4.8)0.003 [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Fibrinogen: A Clinical Update on Liver Transplantation

IntroductionHemostatic and coagulation disorders related to severe liver disease may cause massive bleeding beyond what can be expected from surgical trauma in liver transplantation. Fluid resuscitation and fibrinolysis may aggravate the problem, as plasma fibrinogen decreases in all patients. The objective of this review was to update the criteria for fibrinogen replacement in liver transplantation. MethodsA PubMed and Scopus search from 1990 to 2015 was made. The following key words were used: fibrinogen, liver transplantation, coagulation, and blood product replacement. Controlled trials and observational studies were selected on the basis of clinical relevance. ResultsThere is a scarcity of published controlled studies on perioperative fibrinogen replacement. Most articles refer to expert opinion; therefore, criteria for the administration of fibrinogen have been empirically established. The response to cryoprecipitate or fibrinogen concentrate administration in liver transplantation has not been established. Viscoelastic platelets free tests have been reported to have a good correlation with Clauss-measured plasma fibrinogen concentration. In surgical patients, the median increase in fibrinogen plasma level per gram injected has been determined in 0.2375 g/L. Alternatively, fibrinogen replacement can be guided based on viscoelastic hemostatic assays. ConclusionsIn liver transplantation, plasma fibrinogen levels are low in most patients during surgery. Fibrinogen administration to correct hypofibrinogenemia has a positive impact on surgical bleeding. However, there is a scarcity of literature about fibrinogen administration; therefore, administration should be adjusted to replace plasma fibrinogen levels in the range of normal and guided by thromboelastometry.

Thromboelastography—does it impact blood component transfusion in pediatric heart surgery?

BackgroundThe administration of blood products during pediatric cardiac surgery is common. We sought to determine if thromboelastography (TEG) is a cost-effective tool to reduce blood product transfusion in open pediatric cardiac surgery. Materials and methodsA retrospective case-control study was undertaken for 150 pediatric cardiac patients requiring cardiopulmonary bypass from January 2010–May 2012, in a University-affiliated pediatric hospital. Fifty sequential patients operated on when TEG was used were compared with 100 control patients before TEG availability. Groups were matched 2:1 for age and risk adjustment for congenital heart surgery score. Blood product utilization was compared between groups, as were outcomes metrics such as postoperative complications, length of stay, and hospital costs of transfusions. ResultsDemographic variables, risk adjustment for congenital heart surgery score classifications, and cardiopulmonary bypass times were similar between groups. Red cell and plasma transfusion were comparable between groups. TEG patients saw a substantial reduction in the administration of platelet (1 versus 2.2 U; P < 0.0001) and cryoprecipitate (0.7 versus 1.7 U; P < 0.0001) transfusions. A greater than 50% reductions in hospital costs of platelet ($595 versus $1309) and cryoprecipitate ($39 versus $94) transfusions were observed in the TEG group. Mortality, length of stay, ventilator requirements, postoperative bleeding, and thrombotic events were equivalent. ConclusionsIntraoperative TEG use reduced platelet and cryoprecipitate transfusions without an increase in postoperative complications. TEG is a cost-effective method to direct blood product replacement.

2014 Consensus conference on viscoelastic test–based transfusion guidelines for early trauma resuscitation

There has been an increased interest in the use of viscoelastic testing to guide blood product replacement during the acute resuscitation of the injured patient. Currently, no uniformly accepted guidelines exist for how this technology should be integrated into clinical care. In September 2014, an international multidisciplinary group of leaders in the field of trauma coagulopathy and resuscitation was assembled for a 2-day consensus conference in Philadelphia, Pennsylvania. This panel included trauma surgeons, hematologists, blood bank specialists, anesthesiologists, and the lay public.Nine questions regarding the impact of viscoelastic testing in the early resuscitation of trauma patients were developed before the conference by panel consensus. Early use was defined as baseline viscoelastic test result thresholds obtained within the first minutes of hospital arrival-when conventional laboratory results are not available. The available data for each question were then reviewed in person using standardized presentations by the expert panel. A consensus summary document was then developed and reviewed by the panel in an open forum. Finally, a two-round Delphi poll was administered to the panel of experts regarding viscoelastic thresholds for triggering the initiation of specific treatments including fibrinogen, platelets, plasma, and prothrombin complex concentrates. This report summarizes the findings and recommendations of this consensus conference.

Medical Evaluation of the Surgical Patient

Medical evaluation prior to surgery includes risk assessment and the institution of therapies to decrease perioperative morbidity and mortality to improve patient outcomes. The most effective medical consultation for surgical patients begins with an assessment of the individual patient and knowledge of the planned surgery and anesthesia followed by clear communication of a concise and specific recommended plan of perioperative care to the surgical team. This chapter describes anesthetic, cardiac, pulmonary, hepatic, nutritional, and endocrine risk assessment. Perioperative thrombotic management and postoperative care and complications, including fluid management; pulmonary, cardiac, renal complications; and delirium are discussed. Tables outline the American Society of Anesthesiologists class and perioperative mortality risk, a comparison of the Revised Cardiac Risk Index and National Surgery Quality Improvement Program, Duke Activity Status Index, high-risk stress test findings, markers for increased perioperative risk in pulmonary hypertension, aortic stenosis and nonemergent noncardiac surgery, risk factors for pulmonary complications in noncardiac surgery, the Model for End-Stage Liver Disease score to predict postoperative mortality, venous thromboembolism risk factors and options for pharmacologic prophylactic regimens, perioperative management of warfarin, and Brigham and Women’s Hospital guidelines for postoperative blood product replacement. Figures include a care algorithm for noncardiac surgery, an illustration of types of myocardial infarction, and an algorithm for the treatment of postoperative delirium. This chapter contains 3 highly rendered figures, 12 tables, 68 references, and 5 MCQs.

Two Different Coagulopathy Episodes in a Single Patient with Metastatic Prostate Cancer

We reported a case of two different episodes of critical coagulopathy in a single patient with metastatic prostate cancer (mPC). The patient initially visited the emergency room with a huge left retroperitoneal hematoma, high serum prostate-specific antigen level, and signs of acute disseminated intravenous coagulation (DIC) from mPC. With blood product replacement and anti-androgen therapy, the DIC-related symptoms and signs were relieved. During the follow-up, he was treated with docetaxel chemotherapy for hormone refractory PC. Four years later, he visited the emergency room again with relapsed coagulopathy and severe anemia that were not replaced with blood products. The laboratory findings were consistent with thrombotic thrombocytopenic purpura rather than DIC. A satisfactory recovery was achieved with a new cycle of docetaxel chemotherapy. Differentiation of the coagulopathies in PC is difficult; therefore, we describe the different features of two overlapping coagulopathies, which will be helpful in deciding on urgent treatment.

Coagulopathy Predicts Mortality in Pediatric Patients with Traumatic Brain Injury

Trauma is the leading cause of death in children ages 1 to 21 years of age. Traumatic brain injury (TBI) poses a high risk of both morbidity and mortality within the subset of pediatric trauma patients. Numerous adult studies have shown that coagulopathy is commonly observed in patients who have sustained trauma and that the incidence is higher when there is TBI. Previously, it was thought that coagulopathy related to trauma was dilutional (i.e. due to replacement of red cells and platelets without plasma) but more recent studies show that the coagulopathy in trauma is early and likely independent of transfusion therapy. Additionally, abnormal coagulation studies (PT, PTT, INR, platelet count, fibrinogen, and D-dimer) following TBI are associated with increased morbidity and mortality in adults.Although coagulopathy after traumatic brain injury in adults is well documented, the pediatric literature is fairly sparse. A recent study by Hendrickson et al in 2008 demonstrated that coagulopathy is both underestimated and under-treated in pediatric trauma patients who required blood product replacements. Here we present the results of a retrospective pilot study designed to assess coagulopathy in the pediatric TBI population. We analyzed all children admitted to our facility with TBI from January 2012 to December 2013. Patients were excluded if they had underlying diseases of the hemostatic system. All patients had baseline characteristics measured including: age, sex, mechanism of injury, Glasgow Coma Scale (GCS), injury severity score (ISS), initial complete blood count, DIC profile, hematological treatments including transfusions, ICU and hospital length of stay, ventilator days and survival status. Coagulation studies were defined as "abnormal" when they fell outside the accepted reference range of the pediatric hospital laboratory (PT 12.6-15.9, PTT 23.6-42.1 seconds, fibrinogen < 180 mg/dL units, platelets < 185 103/mL and hemoglobin < 11.5 g/dL). Survival was measured as survival at 30 days from admission or last known status at hospital discharge.One hundred and twenty patients met the inclusion criteria of the study and all were included in outcome analysis. Twenty-three of the 120 patients died (19.2%). Logistic regression analysis was used to compare survivors and non-survivors and baseline demographic data showed no difference in age or weight between the two groups with p-values of 0.1635 and 0.1624, respectively. Non-survivors had a higher ISS (30.26 vs 20.92, p-value 0.0004) and lower GCS (3 vs 5.8, p-value 0.0002) compared to survivors. Univariate analysis of coagulation studies to mortality showed statistically significant odds-ratios for ISS (OR 1.09, 95% CI 1.04-1.15), PT (OR 5.91, 95% CI 1.86-18.73), PTT (OR 6.48, 95% CI 2.04-20.52) and platelets (OR 5.63, 95% CI 1.74 – 18.21). Abnormal fibrinogen levels were not predictive of mortality (OR 2.56, 95% CI 0.96-6.79). These results are summarized in Table 1.Our results demonstrate that, consistent with adult studies, abnormal coagulation studies are also associated with increased mortality in pediatric patients. Higher injury severity scores and lower GCS scores are also predictive of mortality. Taken together, these results suggest that possible early correction of coagulopathy in severe pediatric TBI patients could improve outcomes for these patients.Table 1OR95% CIp-valueISS1.091.04—1.15.0009PT > 15.9 sec5.911.86—18.730.0026PTT > 42.1 sec6.482.04—20.520.0015Fibrinogen < 180 mg/dL2.560.96—6.790.0597Platelets < 185 x 103/mL5.631.74—18.210.0040 DisclosuresNo relevant conflicts of interest to declare.

Audit of emergency laparotomy undertaken at the royal derby hospital compared to the results of the UK emergency laparotomy network; do we meet the optimum standards of care?

s / International Journal of Surgery 12 (2014) S13eS117 S89 0031: AUDIT OF EMERGENCY LAPAROTOMY UNDERTAKEN AT THE ROYAL DERBY HOSPITAL COMPARED TO THE RESULTS OF THE UK EMERGENCY LAPAROTOMY NETWORK; DO WE MEET THE OPTIMUM STANDARDS OF CARE? Aimee Rowe , Sarah Shore, Brett Doleman, David Mulvey, Mike Bewick. Royal Derby Hospital, Derby, UK. Introduction: To compare our performance locally at The Royal Derby Hospital against the recently published National Emergency Laparotomy Audit by the Emergency Laparotomy Network. Methods: Prospective data were collected over a three month period, totalling 85 patients undergoing emergency laparotomy. Data included grade of surgeon and anaesthetist, time of procedure and post-operative destination, and 30 day mortality figures. Results: Mortality locally was similar in all the age groups compared with NELA (P>0.05). Overall 30-day mortality was 14% in the local audit versus 14.9% nationally. Factors found to affect 30-day mortality ranged from underlying pathology to the timing of surgery, with a higher mortality of 20% for the 27/85 cases undertaken ‘out of hours' (00:00-07:59) compared with 10% ‘in hours' (08:00-17:59). Mortality appears to correlate with involvement of consultant anaesthetists/surgeons as more were present ‘in hours'. Post-operative destination was highlighted locally as an area for improvement; 30-day mortality was 17% for patients returning to ICS level 0 care, versus 10% (level 1/2) and 16% (level 3). Conclusions: This study gave insights into current local management of a particularly high-risk patient group. Improved utilisation of critical care units and outreach teams in support of such patients has resulted from this audit. 0274: ROTATIONAL THROMBOELASTOMETRY (ROTEM) e THE FUTURE OF HAEMOSTATIC RESUSCITATION IN MAJOR TRAUMA CENTRES Ruth Bird , James Lawless, Ross Davenport, Claire Rourke, Anne Weaver, Karim Brohi, Daniel Nevin. Royal London Hospital, London, UK. Introduction: Major trauma haemorrhage and coagulopathy are significant factors contributing to early mortality. Routine coagulation testing reflects the initiation phase of haemostasis at the point of testing and is limited in guiding real-time blood product replacement. ROTEM is a point of care test, which measures the interactions of coagulation factors, inhibitors and cellular components during the phases of clotting. It identifies coagulopathies secondary to dilution, consumption, deficiencies and hyperfibrinolysis, providing a rapid guide to haemostatic resuscitation. Methods: Training was initiated in machine use and result interpretation. We devised and implemented a standard operating procedure and robust algorithm, simplifying ROTEM interpretation and blood product replacement therapy into binary steps. Results: The Royal London Hospital Trauma Service introduced ROTEM for “CODE RED”, haemodynamically unstable patients. Creation of a mobile point-of-care unit allows the machine to follow the patient on their journey from admission to intervention. An algorithmic approach to targeted factor replacement therapy has allowed for rapid, widespread utilisation of this technology. Conclusions: Choosing a targeted population of personnel to train, and using a simple algorithmic approach to interpretation and therapeutic decision making; ensures the process is straightforward and easy to utilise when introduced to a major trauma centre. 0326: RE-AUDIT OF TIMELINESS TO EMERGENCY SURGERY: ARE WE MEETING RCS STANDARDS? Hannah Boyd-Carson , Andrew Cheah, Jenny Cole, Chris Horner, Umar Shariff, Haney Youssef. Department of General & Colorectal Surgery, Good Hope Hospital, West Midlands, UK. Introduction: A prospective audit on ”timeliness-to-surgery” for general surgical emergency patients was performed in a district general hospital (July 2012). This demonstrated deficiencies in emergency theatre access compared to RCS recommendations. Following introduction of pre-operative risk stratification and dissemination of audit findings, the aim of this re-audit was to establish if there were improvements in emergency surgical care with respect to RCS standards. Methods: Data on emergency admissions requiring surgical intervention was prospectively collected (1/2/13 3/3/13). Patients were risk stratified for morbidity/mortality rates using P-POSSUM scoring and compared to RCS “timeliness-to-surgery” standards. Results: 53 operations were performed (28% of admissions). Median age 38 years (18-86) with 5.6% post-operative mortality.100% “on-going haemorrhage” and “septic shock” patients went to theatre immediately and within 3 hours respectively; 75% “severe sepsis” patients went to theatre within 6 hours, and 68% “septic” patients went to theatre within 18 hours. Other specialities utilising theatre (30%) and recovery issues (40%) accounted for the main reasons for delays to theatre. Conclusions: Implementation of changes has led to some improvements in timeliness-to-surgery; however two standards were still not met. “Single speciality” theatre allocation and increased recovery staff numbers could potentially improve the delivery of emergency surgical care. 0335: THE LEARNING CURVE OF LAPAROSCOPIC APPENDICECTOMY Wesley Lai , Shelly Griffiths, Stephen Mitchell. South Devon NHS Trust,

Medical Evaluation of the Surgical Patient (SAGHE)

Medical evaluation prior to surgery includes risk assessment and the institution of therapies to decrease perioperative morbidity and mortality to improve patient outcomes. The most effective medical consultation for surgical patients begins with an assessment of the individual patient and knowledge of the planned surgery and anesthesia followed by clear communication of a concise and specific recommended plan of perioperative care to the surgical team. This chapter describes anesthetic, cardiac, pulmonary, hepatic, nutritional, and endocrine risk assessment. Perioperative thrombotic management and postoperative care and complications, including fluid management; pulmonary, cardiac, renal complications; and delirium are discussed. Tables outline the American Society of Anesthesiologists class and perioperative mortality risk, a comparison of the Revised Cardiac Risk Index and National Surgery Quality Improvement Program, Duke Activity Status Index, high-risk stress test findings, markers for increased perioperative risk in pulmonary hypertension, aortic stenosis and nonemergent noncardiac surgery, risk factors for pulmonary complications in noncardiac surgery, the Model for End-Stage Liver Disease score to predict postoperative mortality, venous thromboembolism risk factors and options for pharmacologic prophylactic regimens, perioperative management of warfarin, and Brigham and Women’s Hospital guidelines for postoperative blood product replacement. Figures include a care algorithm for noncardiac surgery, an illustration of types of myocardial infarction, and an algorithm for the treatment of postoperative delirium. This review contains 3 highly rendered figures, 12 tables, and 68 references.

Medical Evaluation of the Surgical Patient

Medical evaluation prior to surgery includes risk assessment and the institution of therapies to decrease perioperative morbidity and mortality to improve patient outcomes. The most effective medical consultation for surgical patients begins with an assessment of the individual patient and knowledge of the planned surgery and anesthesia followed by clear communication of a concise and specific recommended plan of perioperative care to the surgical team. This chapter describes anesthetic, cardiac, pulmonary, hepatic, nutritional, and endocrine risk assessment. Perioperative thrombotic management and postoperative care and complications, including fluid management; pulmonary, cardiac, renal complications; and delirium are discussed. Tables outline the American Society of Anesthesiologists class and perioperative mortality risk, a comparison of the Revised Cardiac Risk Index and National Surgery Quality Improvement Program, Duke Activity Status Index, high-risk stress test findings, markers for increased perioperative risk in pulmonary hypertension, aortic stenosis and nonemergent noncardiac surgery, risk factors for pulmonary complications in noncardiac surgery, the Model for End-Stage Liver Disease score to predict postoperative mortality, venous thromboembolism risk factors and options for pharmacologic prophylactic regimens, perioperative management of warfarin, and Brigham and Women’s Hospital guidelines for postoperative blood product replacement. Figures include a care algorithm for noncardiac surgery, an illustration of types of myocardial infarction, and an algorithm for the treatment of postoperative delirium. This review contains 3 highly rendered figures, 12 tables, and 68 references.

Medical Evaluation of the Surgical Patient

Medical evaluation prior to surgery includes risk assessment and the institution of therapies to decrease perioperative morbidity and mortality to improve patient outcomes. The most effective medical consultation for surgical patients begins with an assessment of the individual patient and knowledge of the planned surgery and anesthesia followed by clear communication of a concise and specific recommended plan of perioperative care to the surgical team. This chapter describes anesthetic, cardiac, pulmonary, hepatic, nutritional, and endocrine risk assessment. Perioperative thrombotic management and postoperative care and complications, including fluid management; pulmonary, cardiac, renal complications; and delirium are discussed. Tables outline the American Society of Anesthesiologists class and perioperative mortality risk, a comparison of the Revised Cardiac Risk Index and National Surgery Quality Improvement Program, Duke Activity Status Index, high-risk stress test findings, markers for increased perioperative risk in pulmonary hypertension, aortic stenosis and nonemergent noncardiac surgery, risk factors for pulmonary complications in noncardiac surgery, the Model for End-Stage Liver Disease score to predict postoperative mortality, venous thromboembolism risk factors and options for pharmacologic prophylactic regimens, perioperative management of warfarin, and Brigham and Women’s Hospital guidelines for postoperative blood product replacement. Figures include a care algorithm for noncardiac surgery, an illustration of types of myocardial infarction, and an algorithm for the treatment of postoperative delirium. This chapter contains 3 highly rendered figures, 12 tables, 68 references, and 5 MCQs.

A principal component analysis of postinjury viscoelastic assays: Clotting factor depletion versus fibrinolysis

The mechanisms driving trauma-induced coagulopathy (TIC) remain to be defined, and its therapy demands an orchestrated replacement of specific blood products. Thrombelastography (TEG) is a tool to guide the TIC multicomponent therapy. Principal component analysis (PCA) is a statistical approach that identifies variable clusters; thus, we hypothesize that PCA can identify specific combinations of TEG-generated values that reflect TIC mechanisms. Adult trauma patients admitted from September 2010 to October 2013 for whom a massive transfusion protocol was activated were included. Rapid TEG values obtained within the first 6hours after injury were included in the PCA. PCA components with an eigenvalue >1 were retained, and, within components, variable loadings (equivalent to correlation coefficients) >|60| were considered significant. Component scorings for each patient were calculated and clinical characteristics of patients with high and low scores were compared. Of 98 enrolled patients, 67% were male and 70% suffered blunt trauma. Median age was 41years (interquartile range 28-55) and median Injury Severity Score was 31.5 (interquartile range 24-43). PCA identified three principal components (PCs) that together explained 93% of the overall variance. PC1 reflected global coagulopathy with depletion of platelets and fibrinogen whereas PC3 indicated hyperfibrinolysis. PC2 may represent endogenous anticoagulants such as the activation of protein C. PCA suggests depletion coagulopathy is independent from fibrinolytic coagulopathy. Furthermore, the distribution of mortality suggests that low levels of fibrinolysis may be beneficial in a select group of injured patients. These data underscore the potential of risk for concurrent presumptive treatment for preserved depletion coagulopathy and possible fibrinolysis.

Novel System for Rapid Assessment of Blood Loss in Elective Surgery and Cesarean Delivery

INTRODUCTION: Visual and gravimetric methods of estimating blood loss are severely limited by human error and the presence of large volumes of amniotic fluid, irrigation, or both. The study goal was to assess accuracy of a novel system for intraoperative monitoring of hemoglobin (Hb) loss. METHODS: After institutional review board approval, 50 patients undergoing elective surgery or cesarean delivery contributed laparotomy sponges intraoperatively. The iPad-based Triton system was used to measure Hb loss (g) and blood loss (mL) by scanning sponges exiting the surgical field. Hemoglobin loss measured by the device was compared with a rinsing (reference) method using linear regression and Bland-Altman analysis. The device's measure of estimated blood loss was compared with the gravimetric method (weighing sponges) and with health care providers' visual estimates. RESULTS: A strong positive linear correlation was observed between the device's measures and the reference method (r=0.91, P<.001). Bland-Altman analysis revealed a bias of 3.7 g Hb and narrow limits of agreement (−15.3 to 22.7 g Hb) between the two measures. Gravimetric method demonstrated a positive linear correlation (r=0.87, P<.001) with the reference method, yet overestimated mean estimated blood loss by 422 mL per patient (667 compared with 245 mL, P<.001). Visual estimation was weakly correlated (r=0.30, P<.05) with the reference method. CONCLUSION: This novel device may enhance the ability to rapidly and accurately quantitate ongoing bleeding and may enable health care providers to better manage fluid and blood product replacement in the setting of obstetric hemorrhage.

Management approach to hemodynamic instability in early postoperative phase

Background: This study aims to investigate the management approach to hemodynamic instability due to several surgical reasons in the early postoperative period. Methods: A total of 222 patients who underwent open heart surgery in our clinic and re-exploration in the intensive care unit (ICU) and operating room between January 2006 and January 2012 were included in the study. The patients were divided into three groups. Group 1 (n=47), which constituted the basis of our study, consisted of the patients re-explored in the ICU with the support of cardiopulmonary bypass (CPB); group 2 (n=65) consisted of patients re-explored without CPB support in the ICU, and group 3 (n=110) consisted of patients re-explored in the operating room in the early postoperative period. The CPB time during the primary surgery, re-exploration time (in hours postoperatively), duration and reason for re-exploration, the primary surgery, the procedure performed in the ICU, the presence of postoperative infection, the length of ICU and hospital stay, the need for blood product replacement, and mortality and morbidity outcomes were compared among the groups. Results: Sixty-four percent of the patients required revision due to massive drainage, 20% due to cardiac arrest, and 16% underwent re-exploration due to malign arrhythmia. Of the patients, 74% had postoperative re-exploration, 12% had support by CPB, 8% had revascularization, and 6% had postoperative complication repair. The mortality rate of the patients who were re-explored in the operating room was significantly lower than the other groups (group 1, 72%; group 2, 45%; group 3, 9%). Conclusion: In the patients in whom open heart resuscitation is obligatory ensuring the operating room conditions quickly and effectively in the ICU is life-saving. Effective and timely support of the CPB is essential for a good postoperative intensive care. This process does not bring an extra burden to the patient, protecting the patient from the time loss and adverse events possibly to be encountered during transport.

HELLP Syndrome Complicated by Subcapsular Hematoma of Liver: A Case Report and Review of the Literature.

Subcapsular liver hematoma (SLH) is a rare complication of severe preeclampsia and HELLP syndrome. These patients must be followed up in intensive care unit for advanced medical support with infused fluid, replacement of blood products, and treatment of underlying disorders. There are a lot of therapeutic options varying from conservative management to surgical treatment including hepatic resection, hepatic artery ligation, and liver transplantation. In this report we aimed to present a 26-year-old woman with SLH secondary to HELLP syndrome.

The Clinical Utility of Tranexamic Acid in the Management of Refractory Bleeding in a Patient With Advanced Liver Disease

Advanced liver disease is associated with coagulopathy and bleeding that develops from several mechanisms. In common clinical practice, the bleeding is treated with blood products and/or pharmacologic agents based on their corrective effect on laboratory tests of hemostasis. We report the case of a 72-year-old man with end-stage liver disease with refractory bleeding in whom multiple therapeutic strategies failed, including massive blood product replacement, but who responded to the infusion of tranexamic acid, an anti-fibrinolytic agent. The hyper-fibrinolytic state is difficult to diagnose with conventional clinical laboratory tests, but it was suspected in this patient with refractory bleeding and hypo-fibrinogenemia. Although largely used in the surgical setting, tranexamic acid may prove useful in medical settings characterized by bleeding and systemic fibrinolysis. J Hematol. 2014;3(2):46-49 doi: http://dx.doi.org/10.14740/jh151w

Hemolytic Anemia as a Result of Piperacillin/Tazobactam Administration: A Case Report and Discussion of Pathophysiology

We report a case of a 19-year-old woman with cystic fibrosis who presented with hemolytic anemia during a course of piperacillin/tazobactam. The patient was initially managed with the replacement of blood products; however, she continued to show signs of hemolysis. Laboratories were obtained confirming antibody formation to piperacillin/tazobactam, and she was given a single infusion of intravenous immunoglobulin. Following the infusion, the patient did not require administration of any further blood products and achieved stable red blood cell counts. Early recognition of hemolytic anemia secondary to piperacillin/tazobactam with the administration of intravenous immunoglobulin may shorten the duration of hospitalization and quantity of blood products required for the stabilization of red blood cell counts.

Recombinant activated factor VII (rFVIIa) for uncontrolled bleeding post cardiac surgery

To review recombinant activated factor VII (rFVIIa) as rescue therapy in persistent severe hemorrhage in post cardiac surgical patients at our institution. A retrospective observational study. From 2004 till April 2010, all patients who received rFVIIa for bleeding of 3 ml/kg/h or more for two consecutive hours after cardiac surgery were included. Surgical bleeding management, patient temperature correction, blood products replacement, and coagulant drugs administration preceded the rFVIIa. The mean for chest tube drainage was significantly lower after the administration of rFVIIa compared to that before (1.2 ± 1.08 vs. 4.1 ± 2.3 ml/kg/h, P = 0.042). There was a significant decrease in the median of: aPTT (43.8 vs. 46.6 s, P = 0.027), ACT (128.9 vs. 131.7 s, P = 0.05), and INR (1.0 vs. 1.43, P = 0.001) after the administration of rFVIIa compared to that before. The median of fibrinogen level and the platelet count showed non-significant increase after the rFVIIa doses (2.57 vs. 2.43 gm/l, P = 0.34 and 106 vs. 101 X109/l, P = 0.27 respectively). Six patients (3.7%) needed re-exploration after the administration of rFVIIa. Five patients (3.2%) had thrombo-embolic complications. The small dose (40–50 mcg/kg) was comparable to high dose (⩾80 mcg/kg) of rFVIIa in terms of: mean chest tube bleeding within the first 4 h, blood products required in the first 24 h, re-exploration for bleeding or thrombotic complications. rFVIIa produced significant reduction in chest tube bleeding post cardiac surgery with reduction in the administration of blood products. Small dose rFVIIa can be considered effective for intractable bleeding after cardiac surgery.

Validity of Estimates of Intraoperative Blood Loss in Pediatric Spinal Deformity Surgery

IntroductionIntraoperative blood loss is a significant concern in pediatric spinal deformity surgery, and numerous reports exist in the literature regarding this issue. Multiple interventions are used to minimize intraoperative blood loss and subsequent need for blood product replacement during and after these procedures. However, a basic question remains regarding the overall accuracy of intraoperative blood loss measurements used to generate these studies. Materials and MethodsWe performed an institutional review board–approved study that compared estimated blood loss (EBL) by the anesthesia provider and surgeon after the completion of surgery for pediatric spinal deformity by a single surgeon. We used the estimate by the anesthesia provider that was to be part of the anesthesia record. The surgeon's estimate was generated based on a formula employing the volume of blood products processed by a Cell-Saver device and available for reinfusion. ResultsWe collected data from 51 patients. The mean EBL (surgeon) was 795.84 mL and mean EBL (anesthesia) was 669.30 mL. The mean percent estimated blood volume loss (%EBVL) (surgeon) was 22.9% and mean %EBVL (anesthesia) was 19.8%. Student t-test analysis demonstrated statistical significance between both sets of values (EBL, p = .010; %EBVL, p = .010). ConclusionsThere was a statistically significant difference in EBL values for this patient sample between the anesthesiologist and orthopedic surgeon; the surgeon's estimates were significantly higher. This difference may be important in interpreting existing studies regarding interventions used to minimize surgical blood loss. In addition, this lack of agreement highlights the need for authors to be more accurate and consistent regarding the source of blood loss data in future clinical studies.