Blood Product Replacement Research Articles

Acute Fatty Liver of Pregnancy Complicated by Pancreatitis and Multiorgan Failure

Purpose: Introduction: Acute fatty liver is an uncommon but serious complication of pregnancy. It usually occurs in third trimester and was universally fatal until the advent of advanced supportive measures. Case: A 29 year old woman was transferred to our tertiary care center with multiorgan failure. She was found to be have liver failure, renal failure and coagulopathy when she first presented to a city hospital with nausea and vomiting in 32nd week of her first pregnancy. Vaginal ultrasonography revealed an intrauterine dead fetus which was evacuated by cesarean section. Upon arrival to our center, she had developed acute pancreatitis, disseminated intravascular coagulation, intraabdominal bleeding with hemorrhagic shock and hypoglycemia in addition to hepatic and renal failure. She was given aggressive supportive treatment and blood products replacement. Transjugular liver biopsy confirmed the diagnosis of acute fatty liver of pregnancy (AFLP). The patient went on to develop acute respiratory failure and sepsis and ultimately succumbed to multiorgan failure. Discussion: Liver dysfunction in pregnancy can range from benign cholestasis to severe preeclampsia, HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome and AFLP. AFLP usually begins in late third trimester with nausea, vomiting, anorexia and epigastric pain and can progress to jaundice, coagulopathy and hepatic encephalopathy. Key laboratory findings are hyperbilirubinemia with modest elevation in transaminases, leukocytosis, coagulopathy and hypoglycemia. It can be complicated by disseminated intravascular coagulation, sepsis, renal failure and, rarely, pancreatitis. It is challenging to differentiate AFLP from HELLP syndrome due to overlapping features and liver biopsy showing microvesicular steatosis is usually necessary to make the diagnosis of AFLP. Emergent delivery and aggressive supportive care is the key to successful outcomes. Resolution occurs spontaneously after termination of pregnancy. Conclusion: AFLP is a serious condition which usually presents with non specific symptoms. Prompt recognition, termination of pregnancy and advanced supportive care are critical determinants of disease outcome. Prognosis is guarded when it is complicated by multiorgan failure.

Traumatic injuries in pregnant women: Anesthesiology aspects

Among the most common predisposing factors that increase the anesthetic-related risks in the management of traumatic injuries are; patients presenting with depressed level of consciousness, full stomach, hypothermia, major blood loss, and screening positive for alcohol or drug abuse. Such patients, therefore, are more likely to respond differently to anesthetic agents. In reference to the current case,1we do not have any data to show patient’s blood pressure, heart rate, respiratory rate and urine output. However, according to her medical chart, we do know that her estimated blood lost was 10-15%. In such circumstances it seems logical to start the patient with intravascular fluid replacement with crystalloids infusion.2In all cases of multiple traumatic injuries, patients are at high risk for cervical spine trauma even when the related signs or symptoms are not present. This is especially important to consider when patient is transported by ambulance, or is transferred between different diagnostic wards, or during the time when rapid sequence induction is mandatory in anesthesia induction time.3,4Safety measures and precautions that are recommended for such cases include; use of appropriately sized Philadelphia collar, placing sand bags on each side of the patient’s head and neck, and resting the patient on a hard board with the forehead taped and secured to the board. These considerations however are often neglected in our practice. Other major risk factors in the management of multiple traumas include; tension pneumothorax, occult blood loss and occult long bone fractures, all requiring vigilance of emergency department physicians and personnel. For anesthesiologists, the choice of selecting a particular anesthetic agent is not as crucial as is deciding what does is more appropriate to use. Thiopental and propofol are appropriate drugs for trauma patients with minor blood loss (below 15%) if given in reduced doses.5Ketamine may be used in the hypovolemic patients. Of note, however, is that occasionally trauma patients, while under emergency care, may endure intracranial injuries with no prominent symptoms. Synthetic opioids, such as fentanil and sufentanil are preferable options for maintenance of anesthesia, but when used alone they carry the risk of awareness during anesthesia, which is quite prevalent in trauma patients. Therefore, anesthesiologist are recommended to use these drugs with some adjutants like benzodiazepines, scopolamine and/or nitrous oxide, if possible.6 Furthermore, management of pregnant women with traumatic injuries calls for immediate consultation and coordinated care with an obstetrician. This is to ascertain the viability and proper care of the fetus. My question in reference to the present case is why the pregnancy was terminated by hysterectomy despite the fact that the fetus was alive and active and had normal fetal heart rates. Also, there was enough amniotic fluid; and there was no laceration or hematoma to the placenta or other solid organs. It is advisable, however, that some anesthetic agents should be avoided in the first trimester of pregnancy to guard against teratogenicity, such as chlordiazepoxide and nitrous oxide.7In hemodynamically unstable trauma patients invasive hemodynamic monitoring is mandatory. This usually consists of continuous intra-arterial blood pressure measurement and central vein cannulation. In addition, patient’s temperature should be monitored regularly and in cases where patient's temperature is below 36oC active warming should be applied. The following care and precautions should be considered while the patient is in the postoperative care unit:, providing sufficient analgesia, balancing of intravascular volume and acid-base status, blood products replacement, identifying strategy for pulmonary emboli prevention due to the long bones fractures and prolonged bed rest, identifying methods of preventing hypothermia, and performing thorough physical exams for detection of any hidden injuries. Presence of lung contusion due to blunt chest trauma is a warning sign that the patient may need postoperative mechanical ventilation and intensive care therapy for several days. Continuous monitoring of the fetus heart rate for detecting fetal distress and unexpected abortion is also highly advised during the management of such patient.

Rotational thromboelastometry (ROTEM) – the future of point of care testing in obstetrics?

IntroductionROTEM is a point of care testing (POCT) device that provides rapid specific coagulation pathway assessment. The use of ROTEM is well established in liver and cardiac surgery, but not...

Placenta accreta

We sought to review the risks of placenta accreta, increta, and percreta, and provide guidance regarding interventions to improve maternal outcomes when abnormal placental implantation occurs. Relevant documents were identified through a search of the English-language literature for publications including ≥1 of the key words "accreta" or "increta" or "percreta" using PubMed (US National Library of Medicine; January 1990 through January 2010); with results limited to studies involving human beings. Additional information was obtained from references identified within selected articles; from additional review articles; and from guidelines by organizations including the American College of Obstetricians and Gynecologists. Each included article was evaluated according to study design and quality in accordance with the scheme outlined by the US Preventative Services Task Force. Abnormal placentation--encompassing placenta accreta, increta, and percreta--is increasingly common. While randomized controlled trials and large observational cohort studies that can be used to define best practice are lacking, strategies to enhance early diagnosis, enhance preparation, and coordinate peripartum management can be undertaken. Women with a placenta previa overlying a uterine scar should be evaluated for the potential diagnosis of placenta accreta. Women with a placenta previa or "low-lying placenta" overlying a uterine scar early in pregnancy should be reevaluated in the third trimester with attention to the potential presence of placenta accreta. When the diagnosis of placenta accreta is made remote from delivery, the need for hysterectomy should be anticipated and arrangements made for delivery in a center with adequate resources, including those for massive transfusion. Intraoperatively, attention should be paid to abdominal and vaginal blood loss. Early blood product replacement, with consideration of volume, oxygen-carrying capacity, and coagulation factors, can reduce perioperative complications.

Point‐of‐care testing in haemostasis

Point-of-care testing (POCT) in haematology has seen a significant increase in both the spectrum of tests available and the number of tests performed annually. POCT is frequently undertaken with the belief that this will reduce the turnaround time for results and so improve patient care. The most obvious example of POCT in haemostasis is the out-of-hospital monitoring of the International Normalized Ratio in patients receiving a vitamin K antagonist, such as warfarin. Other areas include the use of the Activated Clotting Time to monitor anticoagulation for patients on cardio-pulmonary bypass, platelet function testing to identify patients with apparent aspirin or clopidogrel resistance and thrombelastography to guide blood product replacement during cardiac and hepatic surgery. In contrast to laboratory testing, POCT is frequently undertaken by untrained or semi-trained individuals and in many cases is not subject to the same strict quality control programmes that exist in the central laboratory. Although external quality assessment programmes do exist for some POCT assays these are still relatively few. The use of POCT in haematology, particularly in the field of haemostasis, is likely to expand and it is important that systems are in place to ensure that the generated results are accurate and precise.

Disseminated Intravascular Coagulation in Obstetric and Gynecologic Disorders

Disseminated intravascular coagulation (DIC) is a syndrome characterized by a massive, widespread, and ongoing activation of the coagulation system, secondary to a variety of clinical conditions. Many obstetric complications, such as abruptio placentae, amniotic fluid embolism, endotoxin sepsis, retained dead fetus, post-hemorrhagic shock, hydatidiform mole, and gynecologic malignancies, might trigger DIC. In these gynecologic and obstetric settings, DIC is usually associated with high mortality and morbidity rates. No single laboratory test is sensitive or specific enough to diagnose DIC definitively, but it can be diagnosed by using a combination of multiple clinical and laboratory tests that reflect the pathophysiology of the syndrome. At present, the therapeutical approach to pregnancy- and gynecologic-related DIC comprises the specific and aggressive treatment of the underlying disease, eventually followed by a supportive blood product replacement therapy and restoration of physiological anticoagulant pathways. This article reviews the etiopathogenesis, clinical manifestations, laboratory diagnosis, and therapy of pregnancy- and gynecologic-related DIC.

Fluid Resuscitation and Blood Product Replacement in Postpartum Hemorrhage

Abstract This resource is a comprehensive tutorial module for intravenous fluid resuscitation and blood product replacement during the management of postpartum hemorrhage. The module was prepared f...

The effectiveness of routine laboratory findings in determining disease severity in patients with Crimean-Congo hemorrhagic fever: Severity prediction criteria

Background Crimean-Congo hemorrhagic fever (CCHF) is a potentially fatal disease caused by a tick-borne virus from the Bunyaviridae family. Objectives To determine the predictive criteria for severity among patients with CCHF based on clinical and laboratory findings. Study design This retrospective study was conducted on patients with CCHF and hospitalized between June 2004 and August 2008 at Karadeniz Technical University, Turkey. Demographic characteristics, clinical findings and laboratory tests on admission of all patients with CCHF were investigated. Results A total of 152 patients with confirmed CCHF were investigated. Sixty-three (41.4%) of these patients were in the severe group. Laboratory findings using the ROC curve method and optimum diagnostic cut-off points for specific laboratory parameters in the severe group were; PLT: 90,000, Hb: 13.5 g/dL, PT: 13.1 s, aPTT: 34 s, INR: 1, AST: 117 U/L, ALT: 71 U/L, AST/ALT: 1.62, LDH: 508 U/L, CK: 267 U/L and CRP: 0.59 mg/dL. At multivariable analysis, the risk for a severe clinical course in CCHF patients increased 2.59 and 3.93 times in the presence of platelet count and Hb below cut-off values, whereas the same risk increased 2.95, 2.92 and 3.47 times when the results for INR, AST and CRP, respectively, were above the predetermined cut-off values. Conclusions A number of laboratory findings that can easily be measured at routine examination of patients hospitalized with a suspicion of CCHF are valuable and sensitive predictors. These parameters will contribute considerably to the design, practice and management of supportive treatment, blood and blood products replacement and intensive care services.

Damage control surgery in abdominal trauma

The damage control laparotomy is an advancement in the management of massively injured trauma patients. Massive liver injuries, pelvic trauma and some retroperitoneal injuries are some of the indications for this approach. The damage control laparotomy is the phased approach to severe abdominal injury that might best be described with the acronym STIR (Staged Trauma Injury Repair). The initial procedure requires rapid abdominal exploration with hemorrhage and contamination control, using suture repair combined with abdominal packing. Temporary abdominal wall closure without tension is recommended. After abrevated initial surgical procedure, the patient is transferred to the intensive care unit where continued resuscitation is performed. Careful replacement of blood and blood products along with correction of hypothermia, acidosis and optimalization of oxygen transport represents a critical phase in this management approach. Once the coagulation profile has normalized, planned re-intervention, with repeat abdominal exploration to remove the packs and perform definitive surgical repair and reconstruction takes place. When applied judiciously, the damage control laparotomy with the staged abdominal repair and reconstruction for severe trauma is associated with an improved outcome in the selected group of patients.

Severe Thrombocytopenia (

Abstract 4452 IntroductionGlycoprotein IIb/IIIa inhibitors (GPI) improve outcomes in patients following percutaneous coronary intervention (PCI) and troponin positive acute coronary syndrome. However, GPI's can result in severe but transient thrombocytopenia (platelet count <50×109 cells/l). Guidelines on management of this complication are lacking. Minimal data exist on clinical outcomes of this cohort of patients and routine prophylactic use of blood products for these patients is controversial. AimWe aimed to study the clinical course and outcomes of patients with coronary artery disease who were admitted for coronary revascularisation and developed severe thrombocytopenia in coronary care unit of our tertiary cardiac centre. MethodsWe undertook review of 50 consecutive patients who had severe thrombocytopenia. Patients were divided in to two groups, severe thrombocytopenia following GPI usage and severe thrombocytopenia without exposure to GPI (control group). Severe thrombocytopenia in control group was due to co-existent sepsis (4), drugs other than GPI (4), myelodysplasia (4) and unknown aetiology (7). Patients with heparin induced thrombocytopenia, pseudo thrombocytopenia and bypass surgery associated thrombocytopenia and who died within 48 hours were excluded (one in each group). We chose in-hospital mortality, 30-day mortality, repeat coronary intervention and major bleeding as defined by TIMI criteria, as our combined primary endpoint. ResultsData from 27 patients with severe thrombocytopenia following GPI administration and 19 age-matched controls were included for analysis. The GPI group had more males (92.6% vs.78.9%), smokers (29.6% vs.3.7%) and patients with a history of hypertension (59.3% vs.57.9%) and dyslipidaemia (66.7% vs.57.9%). Baseline platelet counts were higher in GPI group (in X109 Cells/l, mean, (SD), 201.63 (78.69) vs. 92.2 (8.02), p<0.05). More number of patients in the GPI group had PCI procedures and coronary stents. Patients in GPI group had major fluctuations and quicker recovery of platelet counts (Figure 1). This group had more patients with minor bleeding without any increase in major bleeding (Table 1). GPI group received fewer blood product transfusions (mean units, blood: 0.07 vs.1.32, p<0.05, platelets: 0.22 vs.1.05, p<0.05). GPI group had significant favourable outcomes such as, lower combined primary end point (3.7% vs.42.1%, p<0.05), lower in hospital mortality (3.7% vs.26.3%, p<0.05) and shorter duration of hospital stay (mean days 3.92 vs.25.08, p<0.05) compared to no-GPI group. ConclusionGPI related severe thrombocytopenia was not associated with an increase in bleeding complications or adverse cardiovascular events. A conservative approach with minimal blood product replacement was safe in this group of patients. These findings may have implications in minimising blood product support in this cohort of patients. [Display omitted] Table 1:Outcomes in patients with severe thrombocytopenia. $$Peak to trough ratio= 100X[(highest–lowest platelet count)/highest platelet count]. Value 100 indicates major fluctuation whereas 0 indicates no change. *P <0.05. SD: standard deviation.GPI group (27)No GPI group (19)Had PCI*96.3%42.1%Number of coronary stents, Mean(SD)*2.04 (1.26)0.37 (1.16)In hospital death*3.7%26.3%Combined end point*3.7%42.1%Major bleeding*015.8%Minor bleeding33.3%26.3%Blood transfusion, in units, Mean(SD) *0.07 (0.38)1.32 (1.95)Platelet transfusion, in units, Mean (SD) *0.22(0.58)1.05 (1.68)Duration of hospital stay. in days, Mean (SD) *3.92 (2.62)25.08 (30.35)Peak platelet count X109 cells/l, Mean (SD) *216.70 (96.62)143.37 (86.57)Trough platelet count X109 cells/l, Mean (SD) *15.0 (13.47)29.37 (9.97)Peak to trough ratio,(SD)*,$$90.54 (12.77)71.01 (19.67) Disclosures:Zaman:British Heart Foundation/FS/07/033: Research Funding.

Factors associated with blood loss and transfusion requirements in craniofacial surgery: a 5 year single-institution review

Introduction: Blood loss remains a major challenge in craniofacial surgery. Despite major advances in both craniofacial surgery and replacement of blood products, this area of practice remains challenging.

Use of Recombinant Activated Factor VII for Intractable Bleeding in Patients Without Hemophilia: A Developing Country Tertiary Care Center’s Experience

Although the use of recombinant activated factor VII (rFVIIa) to control intractable bleeding in nonhemophiliac patients is expanding, several issues pertinent to its potential thrombotic complications and effect on patient mortality are still of concern. We herein describe our experience at a developing country tertiary care center over a period of 4 years. A total of 49 patients were identified of whom 28.6% belong to the pediatric age group. The most common bleeding settings were intracerebral hemorrhage, abdominal aortic surgery, general surgery, and disseminated intravascular coagulopathy. All patients achieved cessation or significant reduction in bleeding. Only 1 patient had a documented postuse thrombotic complication. Of the whole group, 12 patients (24.4%) eventually died with only 1 death having a possible association to rFVIIa use. There was a statistically significant reduction in the need for blood product transfusion after the use of rFVIIa. The use of rFVIIa was in accordance with the hospital's algorithm (identifying salvageable patients, preconditioning, blood product replacement, and dosing) in 30 (61.2%) patients. We conclude that rFVIIa should continue to be considered in nonhemophiliac patients failing to respond to conventional measures of bleeding control. However, this off-label use should be coupled with strict adherence to the treatment algorithms, which remains essential in developing countries with limited health care resources.

Manejo de la hemorragia en pacientes con traumatismo abdominal: aplicación de las Guías Europeas para el manejo del paciente traumatizado sangrante

In patients with traumatic intraabdominal hemorrhage, urgent decisions must be made. Resuscitation measures must often be simultaneously combined with diagnostic actions and measures to control the source of the bleeding. Hemorrhages are usually complicated by coagulation disorders and the presence of acidosis and hypothermia. In these conditions, emergency measures are required that usually involve various specialists. However, given the paucity of the scientific evidence in this field, the intervention protocols differ from one center to another. The European Guidelines for the management of bleeding following major trauma has recently been published. These guidelines review aspects such as evaluation and initial management of bleeding, localization and control of the source of bleeding and replacement of blood products. In addition, recommendations based on the best available evidence to 2008 are made. This review describes the basic aspects of traumatic intraabdominal hemorrhage.

Risk factors for bleeding in pediatric post-cardiotomy patients requiring ECLS

There is limited literature documenting bleeding patterns in pediatric post-cardiotomy patients on extracorporeal life support (ECLS). This retrospective review details bleeding complications and identifies risk factors for bleeding in these patients. Records from 145 patients were reviewed. Patients were divided into excessive (E) and non-excessive (NE) bleeding groups based on blood loss. Excessive bleeding occurred predominantly from 0-6h. Longer CPB duration (NE=174+/-8 min; E=212+/-16; p=0.02) and lower platelet counts (NE=104.8+/-50K; E=84.3+/-41K; p=0.01) were associated with excessive bleeding during the first 6h (p=0.005). Use of intraoperative protamine with normal platelets was associated with decreased bleeding from 7-12 h post-ECLS (p=0.002). Most mediastinal exploration occurred > 49 h post-ECLS, with decreased bleeding post-exploration in E patients. The majority of pediatric post-cardiotomy ECLS bleeding occurs early after support initiation. Longer CPB time and thrombocytopenia increased bleeding 0-6h post-ECLS. Since early bleeding may be coagulopathic in origin, an approach to minimize bleeding includes protamine administration and aggressive blood product replacement with target platelet counts of 100-120K. Surgical exploration should follow if additional hemostasis is necessary.

Transcatheter Arterial Embolization in the Treatment of Maxillofacial Trauma Induced Life-Threatening Hemorrhages

Life-threatening hemorrhages with hemodynamic instability are uncommon in patients with sustained maxillofacial trauma, but when they occur, require immediate surgical intervention if conservative treatment fails. This study assessed the effects of transcatheter arterial embolization (TAE) in the treatment of maxillofacial trauma-induced life-threatening hemorrhages. From January 2004 to January 2007, eight ambulatory patients admitted for maxillofacial injuries with life-threatening hemorrhaging and hemodynamic instability (systolic blood pressure < or = 90 mm Hg) caused primarily by intractable oronasal bleeding who subsequently underwent TAE were included in this study. Maxillofacial trauma was caused by motorcycle traffic injuries (6 cases), motor vehicle injury (1 case), and fall injury (1 case). All patients exhibited documented Le Fort III fractures. The average Glasgow Coma Scale score was 4.7. TAE was successfully performed and hemorrhaging arrested in all patients. Three deaths occurred (38%) from severe traumatic brain injury. The other five patients (62%) survived without development of systemic or neurologic complications post-TAE. Conservative treatment consisting of packing of the nares, compression, and blood transfusion should always precede TAE as the primary protocol. When conservative treatment fails, as shown either by the need for continued blood product replacement exceeding 1,500 mL and a systolic blood pressure < or = 90 mm Hg, TAE intervention should immediately be considered as an alternative recourse before other surgical interventions.

Protocol Based on Thromboelastograph (TEG) Out-Performs Physician Preference Using Laboratory Coagulation Tests to Guide Blood Replacement During and After Cardiac Surgery: A Pilot Study

Allogenic blood transfusion may affect clinical outcomes negatively. Up to 20% of blood transfusions in the United States are associated with cardiac surgery and so strategies to conserve usage are of importance. This study compares administration according to physician's choice based on laboratory coagulation tests with application of a strict protocol based on the thromboelastograph (TEG). Sixty-nine patients presenting for cardiac surgery were randomised to either study or control groups. In the study group a strict protocol was followed covering usage of all blood products according to TEG patterns. In the control group, the physician directed product administration with reference to activated partial thromboplastin time (APTT), international normalised ratio (INR), fibrinogen and platelet count. Bleeding, re-sternotomy, minimum haemoglobin, intubation time, and ICU stay were documented. TEG-based management reduced total product usage by 58.8% in the study group but this was not statistically significant. This was associated with a statistically insignificant trend towards better short-term outcomes. This pilot study suggests that a strict protocol for blood product replacement based on the TEG might be highly effective in reducing usage without impairing short-term outcome.

Upper Airway Obstruction Due to Factor VIII Inhibitor Deficiency

A 62-year-old male patient with known hepatitis C and human immunodeficiency virus coinfection presented with symptoms of acute upper airway obstruction (UAO) requiring endotracheal intubation. The patient was recently placed on warfarin therapy for a newly diagnosed deep venous thrombosis. Imaging of the chest and neck initially suggested an acute/subacute inflammatory/infectious process of the upper airways. He had a prolonged coagulation profile that did not correct with multiple transfusions of blood products. Urgent surgical exploration revealed massive hemorrhage into the muscle and soft tissues of the neck extending to the mediastinum. Hematology abnormalities included a factor VIII activity of 4%, positive mixing studies, and a Bethesda assay 2 BU (Bethesda unit) (low responder) consistent with factor VIII deficiency. The patient's condition eventually improved after blood product replacement and surgical decompression. He was successfully extubated and discharged home. The UAO was likely due to a bleeding complication secondary to either congenital or acquired factor VIII deficiency. It is possible that the use of warfarin contributed to the bleeding. It is critical for the clinicians to consider bleeding disorders and medication complications in patients presenting with UAO and difficult to control coagulopathy or persistently elevated active partial thromboplastin time.

Anaphylactoid syndrome of pregnancy immediately after intrauterine pressure catheter placement

A 35-year-old multipara woman underwent intrauterine pressure catheter placement during labor. Immediately afterwards, she had severe dyspnea develop, became unresponsive, and had a prolonged fetal bradycardia. During emergency cesarean section, she required cardiopulmonary resuscitation repetitively. She then had disseminated intravascular coagulopathy develop and underwent hysterectomy. Anaphylactic reaction may be associated with intrauterine pressure catheter placement.

A Proactive Approach to the Coagulopathy of Trauma: The Rationale and Guidelines for Treatment

Prevalence of coagulopathy in trauma According to the British Committee for Standards in Haematology and the American College of Pathologists, prolongation of the activated partial thromboplastin time (APTT) and prothrombin...

Pediatric Head Injury

Pediatric Head Injury