Severe Intra-abdominal Bleeding Research Articles

Treatment Practices and Outcomes After Blunt Cerebrovascular Injury in Children

Pediatric blunt cerebrovascular injury (BCVI) lacks accepted treatment algorithms, and postinjury outcomes are ill defined. To compare treatment practices among pediatric trauma centers and to describe outcomes for available treatment modalities. Clinical and radiographic data were collected from a patient cohort with BCVI between 2003 and 2013 at 4 academic pediatric trauma centers. Among 645 pediatric patients evaluated with computed tomography angiography for BCVI, 57 vascular injuries (82% carotid artery, 18% vertebral artery) were diagnosed in 52 patients. Grade I (58%) and II (23%) injuries accounted for most lesions. Severe intracranial or intra-abdominal hemorrhage precluded antithrombotic therapy in 10 patients. Among the remaining patients, primary therapy was an antiplatelet agent in 14 (33%), anticoagulation in 8 (19%), endovascular intervention in 3 (7%), open surgery in 1 (2%), and no treatment in 16 (38%). Among 27 eligible grade I injuries, 16 (59%) were not treated, and the choice to not treat varied significantly among centers (P < .001). There were no complications from medical management. Glasgow Coma Scale (GCS) score <8 and increasing injury grade were predictors of injury progression (P = .001 and .004, respectively). Poor GCS score (P = .02), increasing injury grade (P = .03), and concomitant intracranial injury (P = .02) correlated with increased risk of mortality. Treatment modality did not correlate with progression of vascular injury or mortality. Treatment of BCVI with antiplatelet or anticoagulant therapy is safe and may confer modest benefit. Nonmodifiable factors, including presenting GCS score, vascular injury grade, and additional intracranial injury, remain the most important predictors of poor outcome. ATT, antithrombotic therapyBCVI, blunt cerebrovascular injuryCTA, computed tomography angiographyGCS, Glasgow Coma Scale.

Control of severe intra-abdominal hemorrhage with an infusible platelet-derived hemostatic agent in a nonhuman primate (rhesus macaque) model.

Hemorrhage remains the leading cause of potentially survivable trauma mortality. Recent reports indicate that injuries sustained in noncompressible anatomic locations (i.e., truncal and junctional) account for 86.5% of hemorrhage-related deaths. Infusible human platelet-derived hemostatic agents (hPDHAs) represent a promising strategy to reduce blood loss from noncompressible injuries. Here, we evaluate the hemostatic efficacy of a lyophilized hPDHA in a rhesus macaque model of severe, uncontrolled hemorrhage. Hemorrhage was induced via laparoscopic 60% left-lobe hepatectomy in anesthetized rhesus macaques (T = 0 minute). Treatment infusion began with an 11-mL bolus (T = 5-6 minutes) of either 5% albumin solution (control; n = 8) or hPDHA (1.2 × 10(10) platelet equivalents, n = 8), followed by 2.8-mL/min 0.9% normal saline at T = 6-20 minutes. Resuscitation continued with normal saline (0.22 mL/kg/min) to a total volume of 20 mL/kg at T = 120 minutes, at which time surgical hemostasis was achieved and percent blood loss quantified. Animals were monitored until T = 480 minutes and then euthanized, and necropsy was performed with emphasis on intravascular and end-organ thrombi. Data are expressed as mean ± SEM; significance, p < 0.05. Both groups exhibited a ∼70% decrease in mean arterial pressure (MAP) from T = 0-5 minutes. Percent blood loss was 44.2 ± 3.9% in hPDHA animals, and 44.3 ± 3.3% in controls. Survival rates were 4 of 8 for hPDHA animals and 7 of 8 for controls. Regardless of treatment, percent blood loss was greater (p < 0.02) in nonsurviving animals (55 ± 2%, n = 5) compared with surviving animals (42% ± 3%, n = 11). No pathologic intravascular thrombi were observed in either group. The isolated administration of hPDHA did not significantly reduce blood loss; however, thrombocytopenia was not present in the model, and clinically, platelets would be administered in combination with plasma. Mortality was not statistically different between groups (p = 0.14) but was related to blood loss. Future studies should consider the use of hPDHA in combination with additional therapeutics (e.g., factors) and a model that incorporates thrombocytopenia or platelet dysfunction.

An Unusual Case of Acquired Hemophilia a and Factor XIII Consumption

BACKGROUND: Acquired hemophilia A (AHA) results from auto-antibodies that neutralize factor VIII (FVIII) coagulant function. AHA is rare, usually occurring late in life, and occasionally post-partum. It is most often idiopathic, but can be associated with malignancy, autoimmunity, or drugs. In contrast to congenital hemophilia, AHA generally manifests as mucocutaneous bleeding, with poor correlation to antibody titer or residual FVIII activity. Management goals are the achievement of hemostasis and antibody eradication. Here we describe an unusual case of AHA and concomitant factor XIII consumption in a young nulliparous woman.CASE REPORT: A 24-year-old woman with a symptomatic congenital choledochal cyst underwent a Roux-en-Y bypass, bile duct resection and cholecystectomy. Abdominal sepsis ensued from extended spectrum beta-lactamase Klebsiella, with ertapenem initiation on post-operative day (POD) 5. On POD6 she developed severe intra-abdominal bleeding associated with prolongation of the activated partial thromboplastin time (aPTT) from 35 seconds (pre-operative) to 40 seconds (reference interval 28-35 seconds). On POD10, FVIII activity and FVIII inhibitor titer, using the modified Nijmegen Bethesda assay, were measured at 0.08 U/ml and 4.5 BU/ml, respectively. In addition to supportive transfusion therapy, the patient received a sequence of desmopressin (0.3 mcg/kg IV), recombinant FVIII (50 U/kg), and activated prothrombin complex concentrate (aPCC) (50-75 U/kg IV q8h) with tranexamic acid (10-20 mg/kg IV q8h) from POD13-20. Prednisone was concomitantly initiated (1.5 mg/kg/day) (Figure 1). Bleeding persisted despite reduction in clotting time on rotational thromboelastometry post-aPCC. As neither intensified aPCC nor recombinant factor VIIa (rFVIIa) (80 mcg/kg IV q2h) provided substantial benefit, recombinant porcine factor VIII (rpFVIII) was administered from POD20-28 (100 U/kg IV qd). RpFVIII resulted in hemostatic improvement until anti-porcine FVIII antibodies developed on POD27. On POD28, she was transferred to the local hemophilia treatment center where complete factor analysis identified concurrent FXIII deficiency [0.08 U/ml] using a latex immunoassay. FXIII inhibitor analysis using a chromogenic assay was negative. The peak FVIII inhibitor titer and nadir FVIII activity were 74 BU/ml and <0.01 U/ml, respectively. APCC was resumed [POD28-37] and plasma derived factor XIII (pdFXIII) was given every 4 days to maintain FXIII >0.20 U/ml. The patient was also treated with rituximab [POD28,36,43,50]. On POD37, massive intra-abdominal bleeding prompted sequential aPCC, rFVIIa and pd von Willebrand factor (VWF):FVIII concentrate. Once the FVIII inhibitor titer began to wane, bypassing therapy was discontinued and she was managed solely with pdVWF:FVIII. On POD47 all FVIII-related support was discontinued, as the FVIII inhibitor was undetectable and endogenous FVIII normalized. Her FXIII consumption and requirement for FXIII replacement, however, persisted.DISCUSSION: The unusual features of this case of AHA include the patient's young age, the possible triggers for the FVIII inhibitor (extensive abdominal surgery, sepsis, and/or carbapenem use), and concomitant FXIII deficiency. We hypothesize that FXIII deficiency was secondary to consumption from the massive abdominal wound given its persistence despite normalization of hepatic function. Repeated life-threatening bleeding required trials of multiple hemostatic agents. Persistent and prolonged bleeding despite ongoing FVIII replacement should trigger investigation for a concomitant hemostatic deficiency. AHA is a rare condition, and treatment requires intensive monitoring, clinical experience and specialized laboratory support. Current guidelines are largely derived from expert opinion, and contemporary case descriptions for rare disorders are essential to advance options in best care. [Display omitted] DisclosuresSt. Louis:Baxter/Baxalta: Consultancy. Sholzberg:CSL Behring: Honoraria, Research Funding; Baxalta: Honoraria, Research Funding; Amgen: Honoraria.

Evaluation of different radiological interventional treatments of Budd–Chiari syndrome

AimTo evaluate the efficacy of various interventional techniques in treatment of Budd–Chiari syndrome (BCS). Patients methods103 patients with BCS were included in the study. There were 9/103 (8.7%) patients with obstruction of inferior vena cava (IVC) (type I), 17/103 (16.6%) patients with hepatic vein obstruction (type II), 71/103 (68.9%) patients with veno-occlusive diseases (type III) and 6/103 (5.8%) patients with veno-occlusive disease combined with caval thrombosis (type IV). Recanalization techniques of hepatic veins and IVC, and TIPS were used. ResultsOf all the subjects, 101 successfully underwent their procedures, with a technical success rate of 98.06%; only 2 failed to do TIPS. After treatments, 2 patients died after operation because of severe intra-abdominal hemorrhage. One hundred and one patients were followed up for 1–94months. The mean follow-up of a BCS patient treated with PTA was 52.1months, with an overall primary patent rate of 69.2% (18/26). The mean follow-up of BCS treated with TIPS was 33.5months, with an overall primary patent rate of 72.7% (56/77). Eight patients died 7–64months after the interventions. ConclusionsRecanalization of IVC/hepatic vein and TIPS can be regarded as safe and effective interventional invasive methods in the treatment of BCS.

Drug-induced immune thrombocytopenia associated with use of tyrosine kinase inhibitor imatinib

Abstract Since their introduction in the late 1990s, tyrosine kinase Inhibitors (TKIs) have been widely used for the treatment of various cancers. The side effects of the TKI imatinib are well-documented in the literature and include fatigue, skin rash, myelosuppression, and derangement of liver enzymes. Rare side effects have been observed in the postmarketing surveillance and include cardiac tamponade and Steven Johnson Syndrome. In the present report, we present a rare case of imatinib-associated immune thrombocytopenia leading to severe intra-abdominal bleeding. A brief account of similar cases of TKI drug-induced immune thrombocytopenia (DIT) is also described.

Hemoperitoneum - A rare complication in Subserous Uterine Fibroid

Rupture of veins on the surface of sub-serous uterine fibroid is an uncommon cause of hemo-peritoneum. It is usually a silent and serious life threatening gynaecological emergency. We report a case of severe intra-abdominal bleeding secondary to rupture of veins on the surface of subserous fibroid. There was more than two litres of hemoperitoneum with active bleeding from the surface vein of sub-serous fibroid. Total abdominal hysterectomy was done. She received 5 units of fresh blood transfusion The postoperative period was uneventful. A differential diagnosis of rupture of surface vessel of uterine fibroid must be kept, while dealing with a case of hemoperitoneum with pelvic mass.

Self-expanding foam for prehospital treatment of severe intra-abdominal hemorrhage

Noncompressible abdominal bleeding is a significant cause of preventable death on the battlefield and in the civilian trauma environment, with no effective therapies available at point of injury. We previously described the development of a percutaneously administered, self-expanding, poly(urea)urethane foam that improved survival in a lethal Grade V hepatic and portal vein injury model in swine. In this study, we hypothesized that survival with foam treatment is dose dependent. A high-grade hepatoportal injury was created in a closed abdominal cavity, resulting in massive noncompressible hemorrhage. After injury, the animals were divided into five groups. The control group (n = 12) was treated only with fluid resuscitation, and four polymer groups received different dose volumes (Group 1, n = 6, 64 mL; Group 2, n = 6, 85 mL; Group 3, n = 18, 100 mL; and Group 4, n = 10, 120 mL) in addition to fluids. Ten minutes after injury, the foam was percutaneously administered, and animals were monitored for 3 hours. Survival with hepatoportal injury was highest in Group 4 (90%) and decreased in a dose-dependent fashion (Group 3, 72%; Group 2, 33%; Group 1, 17%). All polymer groups survived significantly longer than the controls (8.3%). Hemorrhage rate was reduced in all groups but lowest in Group 4 versus the control group (0.34 [0.052] vs. 3.0 [1.3] mL/kg/min, p < 0.001). Increasing foam dose volume was associated with increased peak intra-abdominal pressure (88.2 [38.9] in Group 4 vs. 9.5 [3.2] in the controls, p < 0.0001) and increased incidence of focal bowel injuries. The self-expanding foam significantly improves survival in a dose-dependent fashion in an otherwise lethal injury. Higher doses are associated with better survival but resulted in the need for bowel resection.

Severe intra-abdominal bleeding leading to hemorrhagic shock, rectal perforation and bilateral hydrothorax after stapling procedure for prolapsed hemorrhoids

Severe intra-abdominal bleeding leading to hemorrhagic shock, rectal perforation and bilateral hydrothorax after stapling procedure for prolapsed hemorrhoids

Severe intra-abdominal bleeding leading to hemorrhagic shock, rectal perforation, and bilateral hydrothorax after stapling procedure for prolapsed hemorrhoids (PPH): is the transanal drainage feasible in this situation?

Severe intra-abdominal bleeding leading to hemorrhagic shock, rectal perforation, and bilateral hydrothorax after stapling procedure for prolapsed hemorrhoids (PPH): is the transanal drainage feasible in this situation?

Severe maternal morbidity in ectopic pregnancy is not associated with maternal factors but may be associated with quality of care

To study the association between patient-related risk factors and severe maternal morbidity in women with tubal ectopic pregnancy (EP). Furthermore, to identify substandard care factors in clinical care management of EP. Case-control study. Not applicable. Case subjects were from the LEMMoN study, a prospective nationwide cohort study. Control subjects were from the ESEP study, an international multicenter randomized controlled trial. Case subjects were women with tubal EP complicated by severe intra-abdominal hemorrhage necessitating blood transfusion of ≥4 units ofpacked red blood cells peri- or postoperatively. Control subjects were women with tubal EP who were hemodynamically stable and surgically treated. Patient-related risk factors as: maternal age, gestational age, previous EP, Chlamydia infection, pelvic inflammatory disease, assisted reproductive techniques, and serum hCG level. Substandard care categories classified as unawareness of the clinician, misdiagnosis, and nonadherence to the guideline on EP. Twenty-nine case subjects and 99 control subjects were included. The mean serum hCG level was significantly higher in case subjects compared with control subjects, but we found no reliable cutoff level of serum hCG to rule out maternal morbidity. Other risk factors did not differ significantly. Substandard care was scored more often in case subjects (43%) than in control subjects (14%), mainly concerning misdiagnosis. No patient-related risk factors for severe intra-abdominal hemorrhage in women with tubal EP were identified. Our findings underpin the importance of awareness of EP among young fertile women and care providers and clinical care management according to the guidelines to prevent severe maternal morbidity.

An Unusual Case of Severe Haemorrhage and Small Bowel Injury Following Percutaneous Suprapubic Catheter Insertion

Suprapubic catheterisation is a useful alternative to urethral catheterisation but it carries potentially serious complications, including bowel injury and infection. We present a case of severe intra-abdominal haemorrhage following a suprapubic catheter insertion using the Seldginger technique. The patient’s risk of complications was increased by a previous hysterectomy. This case demonstrates the use of ultrasound guidance during suprapubic catheterisation in high risk patients, such as those with previous abdominal or pelvic surgery. doi:10.4021/wjnu3w

Emergency surgery due to go-kart injuries: report of two consecutive cases

Injury due to go-karting accidents is a new kind of surgical emergency in Turkey and may show variations between patients. There are special details as relate to the design of the vehicles and patient characteristics. We report two seriously injured patients as a result of two different go-kart accidents. Severe intraabdominal hemorrhage due to liver laceration was seen in one patient and mesenteric intestinal avulsion in the other. Both patients were treated surgically and discharged uneventfully.

Revisiting Splenectomy in Childhood Chronic Immune Thrombocytopenia At the Era of New Therapies: The French Experience

Abstract▪2227▪This icon denotes a clinically relevant abstract Background:While splenectomy is the gold standard treatment for adult's refractory primary immune thrombocytopenia (ITP), its place remains debated in children. The Rare Disease Plan gave us the opportunity to conduct a French collaborative work aiming to study efficiency, tolerance and prognostic factors associated with success of this procedure in childhood ITP. Design and methods:A retrospective study was conducted in France, of less than 18 years old children and adolescents who underwent a splenectomy for ITP during a 9-year period (2000–2009). Data from both the CEREVANCE national cohort and systematic requests to 30 paediatric units were reviewed. Medical data and procedures were checked from patients’ medical records. Complete remission (CR) was defined by platelet count of more than 100 G/L, continuous complete remission (CCR) was defined as CR with no relapse or treatment for at least one year (Aladjidi et al, Haematologica 2011). Relapse-free survival was assessed by Kaplan Meier method. Results:For 78 children in 16 units, the median ages at diagnosis of ITP and at splenectomy were respectively 9.6 (0.8–16.5) and 12.4 (3.5–17.4) years. The median duration of ITP before splenectomy was 24 months (1–162), 62 children had chronic ITP of more than 12 months duration. The surgical procedure was laparoscopy in 81% of children. Four patients experienced post-operative complications: 1 severe intra-abdominal hemorrhage requiring open surgery twelve hours after laparoscopy, 1 pleural and peritoneal hemorrhage after laparotomy, 1 mesenteric and splenic thrombosis and 1 pulmonary atelectasia. With a median follow up of 41 months (1–109), CR and CCR were achieved respectively for 83% and 75% of 62 children with chronic ITP. No overwhelming sepsis was reported during the follow-up. Isotopic platelet studies were available in 10 of the 16 units and assessed in 30 of the 44 concerned children. CR was obtained in 77% of 26 cases with predominant splenic destruction, and in 0% of 2 cases with non splenic destruction. Five-year relapse-free survival was 35% in children of less than 10 years old and 81% in children of more than 10 years old at initial diagnosis of ITP (p=0.0002). Conclusion:This collaborative national study confirms the excellent benefit-risk ratio of splenectomy for refractory chronic ITP, especially in older children. Even if our own results are limited by the small number of patients, prior isotopic platelet studies is useful when locally available. Long term respect of anti-infectious measures is recommended.Acknoledgements to the Association Française pour le Syndrome d’Evans (AFSE), the GIS - Institut des Maladies Rares - INSERM, and the French Health Ministry (Programme Hospitalier de Recherche Clinique 2005, Rare Diseases Plan 2007). Disclosures:No relevant conflicts of interest to declare.

Severe intra-abdominal bleeding from neglected omental implantation of ectopic tissue after methotrexate treatment for persistent ectopic pregnancy

To describe a case of severe intra-abdominal bleeding from omental implants after laparoscopic linear salpingostomy for ectopic pregnancy (EP). Case report. A medical center. A 27-year-old woman, presenting 15 days after methotrexate (MTX) treatment for persistent EP (35 days after laparoscopic linear salpingostomy for EP). Partial omentectomy. Serial β-hCG levels after partial omentectomy. Histopathologic examination confirmed omental pregnancy. Her β-hCG levels decreased rapidly from 1,673 mIU/mL to 1.35 mIU/mL within 14 days after partial omentectomy. Persistent EP after laparoscopic linear salpingostomy can occur in the omentum; meticulous clinical follow-up should be performed, especially when IM MTX injection was used as the salvage treatment for persistent EP.

Clinical complications after transvaginal oocyte retrieval in 7,098 IVF cycles

We report the complications observed after transvaginal oocyte retrieval guided by ultrasound in 7,098 IVF cycles. The frequency of severe complications in our patients was 0.08%, of which four cases were intraperitoneal bleeding (0.06%) and two were cases of ovarian abscess (0.003%).

Management of Hemorrhage in Severe Pelvic Injuries

Major pelvic trauma results in high mortality. No standard technique to control pelvic hemorrhage has been identified. In this retrospective study, the clinical course of hemodynamically instable trauma patients with pelvic fractures treated according to an institutional algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was evaluated. Study variables included demographics, data on the type and extent of injury, achievement of time from admission to hemorrhage control, complications of angiography, red blood cell needs, and outcome. Standard statistical tests were used. Of 1,476 pelvic fracture patients, 45 fulfilled the inclusion criteria. Two patients presented with severe intra-abdominal hemorrhage and underwent emergency laparotomy with pelvic packing. Forty-two patients underwent angiographic embolization before (n = 24) or after (n = 18) a computed tomography scan. Applying the clinical algorithm, pelvic hemorrhage was controlled in all but one patient who died before any intervention could be initiated (97.8%). The hourly need for red blood cell transfusions decreased during 24 hours after angiographic embolization when compared with before the procedure (3.7 +/- 3.5 vs. 0.1 +/- 0.1 U/h; p < 0.001). In patients undergoing angiographic embolization, the mean time to hemorrhage control was 163 minutes +/- 83 minutes. Hospital mortality was 26.2%. Two patients required reembolization because of hemorrhage from other than the primary bleeding site. One patient developed gluteal necrosis, and nine subsequently required renal replacement therapy. Application of a clinical algorithm focusing on basic radiologic diagnostics, external fixation, and early angiographic embolization was effective and safe to rapidly control hemorrhage in hemodynamically instable trauma patients with pelvic fractures.

Severe intraabdominal bleeding caused by endometriotic lesions during the third trimester of pregnancy

Endometriosis is known to be associated with an increased risk for early pregnancy complications, including ectopic pregnancy and miscarriage. However, little has so far been reported on complications linked to severe endometriosis occurring during the third trimester of pregnancy. A retrospective review of 800 women attending the endometriosis clinic of the Sheba Medical Center during the years 2002-2006 was performed. Cases with severe endometriosis and associated complications during late pregnancy were identified. Three women were found who experienced significant intraabdominal bleeding in the third trimester of pregnancy attributed to a lesion resulting from severe endometriosis. The intraabdominal bleeding occurred between 26-29 weeks of gestation. In all cases the major presenting prenatal symptom was severe lower abdominal pain. The pain was not relieved by the administration of tocolytics or mild analgesics. Explorative laparotomy, performed in all 3 cases, revealed the presence of significant intraabdominal bleeding requiring immediate transfusion of blood products stemming from endometriotic lesions. Fetal complications occurred in all 3 cases. The symptoms of endometriosis are often relieved during pregnancy. Yet lesions caused by severe endometriosis can lead to significant intraabdominal bleeding during the third trimester of the pregnancy. Physicians must be aware that close antenatal follow-up and prompt intervention may be required in such cases.

Pancreatic head resection: the risk for local and systemic complications in 1315 patients—a monoinstitutional experience

Pancreatic head resection is a major surgical procedure and even today is linked to considerable risk for severe complications. In high-volume centers, morbidity and mortality after pancreatic head resection decreased to below 5%. In the authors’ monoinstitutional experiences including 1315 patients with malignant lesion and benign tumor, the frequency and severity of local as well as systemic complications after pancreatic head resection are reported. Between 1982 and 2004, 1315 patients underwent several types of pancreatic head resections including 549 patients with periampullary cancer, 57 with cystic neoplastic lesions, 61 with neoplasia of the papilla, 18 with endocrine tumors, and 630 with inflammatory head tumors in chronic pancreatitis. Kausch-Whipple resection was applied in 208 patients, pylorus-preserving pancreatic head resection in 412, duodenum-preserving pancreatic head resection in 571, total pancreatectomy in 36, and ampullectomy in 61 patients. Pancreatic fistula was observed in 6.8% and a breakdown of pancreaticojejunostomosis in 2.5% of the patients. Gastrointestinal leakage occurred in 0.5%. Pancreatic fistula was managed nonsurgically in 84 of 89 patients. However, the breakdown of pancreatic anastomosis requiring completion pancreatectomy developed in 29 of 33 patients. The hospital mortality of the breakdown of pancreaticojejunostomosis rose up to 34.5%; hospital mortality in patients with pancreatic fistula was 3.6%. The total hospital mortality in 1315 patients after head resection was 2.05%. Risk factors with significant relation to outcome criteria on nonsurvival are the breakdown of pancreaticojejunostomosis, severe intra-abdominal bleeding, intra-abdominal abscess, and postoperative multiorgan dysfunction syndrome. Pancreatic fistula as well as biliary leakage did not significantly determine outcome. Pancreatic head resection for neoplastic and benign tumor lesions of the pancreatic head using different resection techniques is still a major surgical procedure but with a low risk for severe complications in a high-volume center. Pancreatic fistula is a local complication that results in a prolongation of hospital stay but does not contribute to mortality and reoperation. However, the breakdown of pancreaticojejunostomosis is a life-threatening complication causing abdominal sepsis.

Failure of recombinant factor VIIa in a patient with severe polymicrobial sepsis and postoperative uncontrolled intraabdominal bleeding

BackgroundThis report discusses a case of unsuccessful treatment with recombinant factor VIIa (rFVIIa) in off-label use. The need for international guidelines concerning the off-label use of rFVIIa is outlined as well as the need for methods to control the efficacy of rFVIIa objectively.Case presentation54 year old male with severe polymicrobial sepsis due to a perforated diverticulitis of the sigmoid colon and consecutive overt disseminated intravascular coagulation. He suffered severe intraabdominal bleeding after abdominal surgery despite conventional haemostatic support. Repeated applications of factor VIIa temporarily improved coagulation essays but did not stop clinical bleeding. The patient died in multiorgan failure due to septic and haemorrhagic shock.ConclusionOff-label use of rFVIIa could result in more side effects than could be expected from literature because of a publication bias. However for most off-label applications large prospective, randomised and controlled trials to confirm the positive findings are missing. For the future, not only guidelines concerning the off-label use of rFVIIa are urgently needed but also guidelines for monitoring the efficacy of rFVIIa.

Adrenal Haemorrhage with Cholestasis and Adrenal Crisis in a Newborn of a Diabetic Mother

The large hyperaemic foetal adrenal gland is vulnerable to vascular damage. This may occur in the neonatal period as a consequence of difficult labour, or its aetiology may not be apparent. The spectrum of presentation is considerable, ranging from asymptomatic to severe life-threatening intra-abdominal haemorrhage. The presentation of adrenal insufficiency may be delayed but the regenerative capacity of the adrenal is great, and most adrenal haemorrhage is not associated with significantly impaired function. Some reports showed that cholestatic hepatopathy with congenital hypopituitarism reversed by hydrocortisone treatment is considered in the context of the endocrine syndrome, probably as a consequence of the adrenal failure. We describe a case of bilateral adrenal haemorrhage with hepatitis syndrome and persistent hypoglycaemia in a newborn male with striking features of neonatal cholestasis and adrenal crisis.