Severe Blood Loss Research Articles

Massive right-sided colon diverticular bleeding complicated by the transfusion related acute lung injury (TRALI)

Abstract Colonic diverticulosis is a condition which causes extensive bleeding of the lower gastrointestine in 40–50% of cases. In particular, right-sided diverticulosis, although uncommon requires lifesaving colectomy. Transfusion related acute lung injury (TRALI) is a transfusion reaction, which can occur after administration of various blood products. Although life threatening, it can be completely reversed usually within 72 to 96 hours. Here, we report a case of a young Caucasian male hospitalized due to severe anemia, hematochezia and extensive blood loss, all due to lower gastrointestinal hemorrhage from right-sided diverticulosis. These conditions were overlooked endoscopically and diagnosed then treated surgically with the right-sided hemicolectomy. During postoperative course, four hours after the last transfusion, patient developed fever, hypoxia and noncardiogenic pulmonary oedema, but made complete recovery through aggressive oxygen support within 96 hours. The aim of this case was to review current literature, to draw attention to a serious and under-diagnosed transfusion reaction, as well as discuss possible explanations for the diagnostic difficulties that occurred in this case.

VACUUM EXTRACTION AND FORCEPS DELIVERIES;

Objective: To compare the maternal and neonatal morbidity between vacuum extraction versus forceps vaginal delivery. Studydesign: Quasi-experimental study. Period: January 2009 to December 2010. Setting: Department of Obstetrics and Gynecology CMC,SMBBMU Larkana. Methodology: All patients delivered by forceps or vacuum with singleton pregnancy were included, the patient withmultiple gestation, breech presentation and gestational age less than 34 weeks were excluded. Data collected in pre-set Proforma include typeof instrument used, indication of instrumental delivery, maternal and neonatal complications of procedure. Data was analyzed; frequency andpercentage will be calculated for maternal age, gestational age, and degree of perineal and cervical tears. .chi-square test was applied tocompare the degree of neonatal and maternal complications. P-value less than 0.05 taken as significant. Results: Total 9, 5600 deliveries wereconducted, among them assisted vaginal deliveries were169 making the frequency of 2.66%, among which 96 have forceps and 64 wereventouse vaginal deliveries. Majority of women were primigravida. In infants of less than 37 weeks of gestation the use of forceps wassignificantly more common, delay in second stage of labor was the most common indication for vacuum extraction while fetal distress was morecommon reason for forceps delivery. Severe birth canal injuries (third and fourth degree perineal tears) and procedure related blood loss ofmore than 500 ml was significantly more common in forceps delivery group. Cephalhaematoma, neonatal jaundice and severe caputsuccedanum at discharge were more seen in vacuum deliveries, but facial injuries were more common after forceps delivery. Intracranialhemorrhage was identified in two infants born by vacuum extraction and none in forceps group. Two infants delivered by vacuum extractionexpired, one due to respiratory distress and other due to intracranial hemorrhage, and one of the infants delivered by forceps expired due tomeconium aspiration syndrome (MAS). Conclusions: Each instrument has its own merits and demerits .Maternal and neonatal outcomedepends on indications of instruments, patient selection and skill of operator. We conclude that forceps delivery is more associated withmaternal genital tract trauma and vacuum delivery is associated with more neonatal complications. So it is the choice of obstetrician to selectthe proper instruments . We also suggest that obstetricians learn these skills not on patients but in a skill laboratory using models.

Increased morbidity and mortality after bilateral femoral shaft fractures: Myth or reality in the era of damage control?

IntroductionBilateral femoral shaft fractures have been reported to be an independent risk factor for morbidity and mortality; however, the value of these studies is limited due to small sample sizes and the timing of these studies before the establishment of damage control orthopaedics. The objective of this study was to compare the incidence of morbidity and mortality in patients with bilateral vs. unilateral femoral shaft fractures in the era of damage control orthopaedics. MethodsRetrospective analysis of the TraumaRegister DGU from 2002 to 2005. Inclusion criteria were uni- or bilateral femoral shaft fractures and complete demographic data documentation. Univariate data analysis and logistic regression analysis were performed with SPSS. ResultsBetween 2002 and 2005, 776 patients with unilateral and 118 patients with bilateral femoral shaft fractures were identified. Patients with bilateral femoral shaft fractures had a significantly higher Injury Severity Score (ISS) (29.5 vs. 25.7 points), a significantly higher incidence of pulmonary (34.7% vs. 20.6%) and multiple organ failure (25.0% vs. 14.6%) as well as a significantly higher mortality rate (16.9% vs. 9.4%). In the overall patient population, early total care (ETC) was significantly more often performed in patients with unilateral femoral shaft fractures (50.9% vs. 33.6%). Logistic regression analysis revealed no significant association between bilateral femoral shaft fractures and multiple organ failure or mortality; however, bilateral femoral shaft fractures are an independent risk factor for pulmonary failure. Subgroup analysis revealed that the impact of the bilateral femoral shaft fracture was especially pronounced in patients with an ISS<25 points. DiscussionBilateral femoral shaft fractures are an independent risk factor for pulmonary failure but not for multiple organ failure or mortality. The impact of the additional femoral shaft fracture for pulmonary failure appears to be especially pronounced in the less severely injured patients, whose injuries are often underestimated when stratified with the ISS. Patients with bilateral femoral shaft fractures have significantly more often severe abdominal injuries as well as severe blood loss which may account for the increased mortality rate. Therefore, the presence of bilateral femoral shaft fractures should be recognised as an increased risk for systemic complications.

Stroke due to anemia after severe menstrual bleeding caused by a uterine myoma: the title is self-explanatory

To the Editor,Cerebral infarction results from acute impairment of oxy-genated blood flow either due to a thrombotic or embolicocclusion. Aside from several likely contributing factors[1], anemia is an overlooked risk factor for cerebralinfarction. Although the relationship between anemia andcerebral infarction has not been well established, severalresearchers reported an association between these twoconditions [2–4].Likewise, we report a patient who had acute cerebralinfarction associated with severe anemia following severeblood loss due to a uterine myoma.A 43-year-old woman was admitted for a sudden onsetof weakness on her left side. Her medical history did notdisclose any risk factor like systemic hypertension, vas-cular malformation, coagulopathy, hyperlipidemia, smok-ing, diabetes mellitus, prior stroke history or positivefamily history. Her cardiac examination including elec-trocardiography and echocardiography was also normal.The laboratory findings were as follows: hemoglobin (Hb):5.7 g/dL (12.8 g/dL 1 month ago), hematocrit (Hct): 21.0,serum iron: 11.9 mg/dL (50–150) and platelet count:594,000/lL. Cranial magnetic resonance imaging (MRI)showed an infarction in the middle cerebral artery suppliedarea (Fig. 1). Overall, the patient was diagnosed to have anischemic cerebral infarction associated with severe anemia.Thereafter, she was given anti-thrombolytic treatment andblood transfusion twice for anemia. Further evaluationsregarding etiology were not contributory except hypo-chromic microcytic anemia. On detailed questioning, shedeclared that her complaints started within the 2 days aftera major bleeding during menstruation. She added that sheusually had similar menstrual bleedings before as well.Upon consultation to the gynecology department, she wasdiagnosed with a huge uterine myoma. She was thenscheduled for hysterectomy in a week after hemodynamicstabilization. After a 2-week rehabilitation program, thepatient discharged was almost independent in her dailyliving.In the previous literature, there are a few anecdotalreports on the association between bleeding, anemia andcerebral infarction [2–4]. Although the relationship amongthem was unclear, Akins et al. [5] presented patients withsevere iron deficiency anemia in whom reactive thrombo-cytosis led to thrombus formation and thus cerebralinfarction. Likewise, Kim et al. [6] also consideredbleeding and subsequent anemia to be a precipitant forcerebral infarction. In that study, they have also reportedthrombocytosis, especially in patients with chronic irondeficiency anemia. In another study whereby patients withanemia—due to acute blood loss—but without iron defi-ciency were enrolled, Tsai et al. [2] mentioned that acuteanemia could induce cerebral blood flow insufficiency anddecreased oxygen-carrying capacity, with an eventual tis-sue hypoxia especially at the most vulnerable regions.Selective decrease in hematocrit has also been reported to

Bleeding from the Excluded Gastric Remnant after Roux-en-Y Gastric Bypass Controlled with Mesenteric Angiography

Introduction: We present a rare case of life threatening gastrointestinal bleeding from excluded gastroduodenal remnant after Roux-en-Y gastric bypass that was successfully controlled with mesenteric angiography and coil embolization of the proximal branch of the gastroduodenal artery (GDA). Case Report: A 43-year-old male with medical history of laparoscopic Rouxen-Y gastric bypass done for morbid obesity in 2006 presented with complaint of black tarry and maroon colored stools for one day prior to admission. He was using NSAIDs for chronic back pain. His vitals were stable at the time of admission. Patient was placed on proton pump inhibitor drip. Physical examination was significant for pallor and dark red blood on rectal examination. Initial laboratory data were significant for hemoglobin of 7.3gm/dl, Platelets of 167 K/μL and INR was 1.5. Patient was started on proton pump inhibitor drip and he was transfused initially with four units Packed Red Blood Cell (PRBC). Esophagogastroduodenoscopy (EGD) was performed and two small ulcers were found at the anastomotic site. Both of them had a clean base. One of the ulcers was deep linear ulcer with minimal oozing where epinephrine was injected and two hemoclips were placed with control of the oozing. Few hours later, patient developed hypovolemic shock after he had multiple episodes of hematemesis and maroon colored stools. He received an additional nine units of PRBCs and two units of fresh frozen plasma. Mesenteric angiogram was performed emergently as the severity of blood loss was unduly higher than the findings of EGD. It showed active bleeding from the proximal branch of GDA that was successfully embolized with two small micro-coils. Patient stabilized afterwards and he recovered. The GDA supplies the excluded gastroduodenal segment of the gastric bypass that was not visualized on EGD. Discussion: The incidence of bleeding after gastric bypass is estimated to be between 0.8 and 4.4%. Marginal ulcer is the most common cause of bleeding after gastric bypass. Bleeding from the excluded gastric remnant after Roux-en-Y gastric bypass is a rare event. Evaluation of the excluded gastric remnant is challenging and was limited to intraoperative gastrotomy and intraoperative endoscopy through the gastrotomy. Double balloon enteroscopy has been recently used to evaluate and control bleeding from excluded gastric remnant. We present a rare case in which mesenteric angiography was used to control bleeding from excluded gastric remnant that could be particularly useful especially in centers where double balloon enteroscopy is not readily available.

Management of Large Bowel Injury During Laparoscopic Surgery

Management of Large Bowel Injury During Laparoscopic Surgery

Blood Loss during Flexible Bronchoscopy: A Prospective Observational Study

Background: Haemorrhage remains a complication of flexible bronchoscopy. Objectives: We aimed to measure the actual blood loss in patients at low risk of bleeding and to assess its association with the underlying pulmonary pathology, superior vena cava (SVC) syndrome, procedure(s) performed and laboratory values. Methods: We screened all patients scheduled for flexible bronchoscopy and enrolled 234 subjects over 18 months. Subjects with a history of haemorrhagic tendency, platelets <20 × 10³/µl, a history of anti-coagulation or anti-platelet therapy and a history or clinical evidence of liver failure were excluded. Blood loss during the procedure was measured from aspirated secretions with a haemoglobin detector and categorised into minimal (<5 ml), mild (5–20 ml), moderate (20–100 ml) and severe bleeding (>100 ml). Results: Overall, 210 subjects had minimal, 19 had mild and 5 had moderate bleeding. No subject experienced severe blood loss. Patients with SVC syndrome had the highest mean blood loss (6.0 ml) when compared to bronchogenic carcinoma without SVC syndrome (p = 0.033) and other diagnosis (p = 0.026). The blood loss with trans-bronchial needle aspiration (TBNA, mean 3.4 ml) was significantly less than with TBNA combined with endobronchial or transbronchial biopsy (mean 5.0 ml, p < 0.001). Anaemia, a platelet count of 25–155 × 10³/µl and an international normalized ratio of >1.3 were not associated with an increased risk of bleeding. Conclusions: We found no severe bleeding in this cohort preselected to have a low clinical risk of bleeding. Moreover, our data suggest that clinical screening and a platelet count ≥20 × 10³/µl alone may be sufficient to identify low-risk patients.

Should antifibrinolytics be given in all patients with trauma?

Hemorrhage is the second most important cause of death in patients with trauma, contributing to approximately 30% of trauma-related mortality. Pharmacological prohemostatic agents may be useful adjunctive treatment options in patients with severe blood loss. Tranexamic acid was evaluated in a large international randomized controlled study in patients with trauma and severe blood loss. The drug was shown to reduce death due to bleeding, provided the treatment was given within 3 h after injury. Tranexamic acid treatment did not result in serious adverse events nor thrombotic complications. In view of this efficacy and safety of this relatively cheap and simple drug, it may be recommended to put tranexamic acid in the first (maybe even prehospital) line of management of patients with severe traumatic hemorrhage.

Extraction and purification of recombinant human serum albumin from Pichia pastoris broths using aqueous two-phase system combined with hydrophobic interaction chromatography

Recombinant human serum albumin (rHSA) is considered as an alternative of human serum albumin and used to treat patients with severe burn, shock or blood loss. However, separation and purification of rHSA are difficult and have become the bottle neck in industrial production. In this study, ethanol/K2HPO4 aqueous two-phase system (ATPS) and hydrophobic interaction chromatography (HIC) were integrated to provide a new approach for the extraction and purification of rHSA from high density fermentation broth. Using a 0.01–73L ATPS scale, the extraction of rHSA from the fermentation broth attained an average recovery of 100.4%. At the same time, 99.8% of cells and 87.2% of polysaccharides as well as some other protein impurities were also removed. The activity of proteinase A in the broth was also remarkably decreased. The purified rHSA appeared as a single band on reduced SDS–PAGE gel, and it had a purity of 99.1% as determined by HPLC. It was essentially identical to the plasma-derived HSA in terms of molecular weight and circular dichroism spectrum. The total recovery of rHSA was 75.2%, which was 1.1–2.0 times higher than that obtained from conventional processes. Residual polysaccharide was reduced to 1.61μg/mg rHSA and the degree of coloring was lower than that of plasma-derived HSA. The procedure employed in this study has the advantages of simple operation, shorter time, low energy consumption and high yield, and it could produce rHSA with high purity. It is therefore suitable in the production of rHSA and other biological products produced by high-density fermentation.

Comparative treatment and literature review for laparoscopic splenectomy alone versus preoperative splenic artery embolization splenectomy

Although laparoscopic splenectomy has been gradually regarded as an acceptable therapeutic approach for patients with massive splenomegaly, intraoperative blood loss remains an important complication. In an effort to evaluate the most effective and safe treatment of splenomegaly, we compared three methods of surgery for treating splenomegaly, including open splenectomy, laparoscopic splenectomy, and a combination of preoperative splenic artery embolization plus laparoscopic splenectomy. From January 2006 to August 2011, 79 patients underwent splenectomy in our hospital. Of them, 20 patients underwent a combined treatment of preoperative splenic artery embolization and laparoscopic splenectomy (group 1), 30 patients had laparoscopic splenectomy alone (group 2), and 29 patients underwent open splenectomy (group 3). Patients' demographics, perioperative data, clinical outcome, and hematological changes were analyzed. Preoperative splenic artery embolization plus laparoscopic splenectomy was successfully performed in all patients in group 1. One patient in group 2 required an intraoperative conversion to traditional open splenectomy because of severe blood loss. Compared with group 2, significantly shorter operating time, less intraoperative blood loss, and shorter postoperative hospital stay were noted in group 1. No marked significant differences in postoperative complications of either group were observed. Compared with group 3, group 1 had less intraoperative blood loss, shorter postoperative stay, and fewer complications. No significant differences were found in operating time. There was a marked increase in platelet count and white blood count in both groups during the follow-up period. Preoperative splenic artery embolization with laparoscopic splenectomy reduced the operating time and decreased intraoperative blood loss when compared with laparoscopic splenectomy alone or open splenectomy. Splenic artery embolization is a useful intraoperative adjunctive procedure for patients with splenomegaly because of the benefit of perioperative outcomes.

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

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

Mitochondrial transcription factor A is a proinflammatory mediator in hemorrhagic shock

Endogenous molecules released by dying cells [i.e., damage-associated molecular patterns (DAMPs)] after trauma and severe blood loss can activate pattern recognition receptors, leading to a cascade of inflammatory responses and organ injury. Mitochondrial transcription factor A (TFAM) is a transcription factor for mitochondrial DNA. TFAM is structurally related to high mobility group box 1 (HMGB1), an important member of DAMPs. We, therefore, hypothesized that TFAM can be released into the circulation after hemorrhage to initiate inflammatory responses. In order to examine this hypothesis, male Sprague-Dawley rats were bled to and maintained at a mean arterial pressure of 40 mmHg for 90 min. They were then resuscitated with an equal volume of shed blood in the form of Ringer’s lactate (i.e., low-volume resuscitation) over 60 min. TFAM levels in the serum were measured at 4 h after hemorrhage and resuscitation. Our results showed that serum levels of TFAM were more than doubled after hemorrhage and resuscitation. To further characterize TFAM’s biological activity, we expressed recombinant rat TFAM with a GST-tag (GST-TFAM) in an E. coli expression system. The purity of GST-TFAM was over 99% and it was immunoreactive for specific anti-TFAM antibodies. Using RAW 264.7 cells and primary rat peritoneal macrophages, we showed that GST-TFAM dose-dependently increased TNF-α release. To determine the biological activity of GST-TFAM in vivo, GST-TFAM was intravenously injected in healthy male adult rats. Our results demonstrated that intravenous injection of GST-TFAM, not GST alone, upregulated circulating levels of pro-inflammatory cytokines, increased neutrophil infiltration to the lungs and caused organ injury in healthy animals. Thus, TFAM can act as a DAMP and may contribute to the initiation of inflammatory responses in hemorrhagic shock.

Themes in maternal deaths in a tertiary hospital, Zambia

BackgroundA needs assessment of women's health services was conducted in support of a WHO sponsored link between Guys and St. Thomas' Hospital, London, and Ndola Central Hospital, Zambia. Ndola Central...

Resting sympathetic baroreflex sensitivity in subjects with low and high tolerance to simulated hemorrhage with lower body negative pressure

Central hypovolemia elicited by hemorrhage or lower body negative pressure (LBNP) triggers autonomic reflexes to maintain organ perfusion; these reflexes fail with severe blood loss resulting in cardiovascular collapse. The ability to tolerate LBNP is variable and factors contributing to tolerance are unclear. We tested the hypothesis that resting sympathetic baroreflex sensitivity (BRS) is attenuated in subjects who have a low tolerance (LT) to LBNP. Muscle sympathetic nerve activity (MSNA) and diastolic arterial pressure (DAP) were recorded in 48 human subjects who subsequently underwent LBNP to presyncope. LT subjects reached presyncope prior to completing −60 mmHg LBNP, and high tolerant (HT) subjects experienced presyncope after −60 mmHg LBNP. BRS was assessed as the slope of the relationship between spontaneous fluctuations in DAP and MSNA during 5 min of supine rest. MSNA burst incidence/ DAP correlations were strong (r&gt;0.5) in 36 subjects (LT: n= 8; HT: n=28), and BRS was not different between LT and HT (−1.91 ± 0.31 vs. −2.24 ± 0.22 bursts·(100 beats)−1·mmHg−1, p=0.45). MSNA total activity/ DAP correlations were strong (r&gt;0.5) in 34 subjects (LT: n= 8; HT: n=26), and BRS was not different between LT and HT (−592 ± 69 vs. −666 ± 70 arbitrary units·(beats)−1·mmHg−1, p=0.58). We conclude that resting MSNA BRS does not influence tolerance to LBNP. Funded by the US Army Medical Research and Materiel Command.

Renal responses to severe haemorrhage in conscious lambs

The role of the kidney in the physiological responses to severe degrees of haemorrhage beyond which compensatory mechanisms fail (&gt;25% of vascular volume) has not been investigated in the newborn period. In this study, parameters of glomerular and tubular function were measured for 30 min before (Control, C) and 120 min after haemorrhage of 30% of vascular volume, in conscious, chronically instrumented lambs aged ~one (N=10) and ~six weeks (N=9). Renal plasma flow decreased 30 min after haemorrhage from 1.4±0.5 SD (C) to 0.7±0.2 mL.min−1.g−1 at one week and from 1.6±0.4 (C) to 0.9±0.4 mL.min−1.g−1 at six weeks and remained decreased at 120 min. Similarly, glomerular filtration rate decreased from 0.26±0.08 (C) to 0.18±0.14 mL.min−1.g−1 at one week and from 0.31±0.08 (C) to 0.17±0.08 mL.min−1.g−1 at six weeks, and remained below C at 120 min. Urinary flow rate also decreased from 3.8±1.6 (C) to 1.8±0.7 uL.min−1.g−1 by 30 min after haemorrhage at one week and from 3.9±1.5 (C) to 2.2±0.8 uL.min−1.g−1 at six weeks, and remained below C at 120 min. Clearances of Na+ and K+ also decreased after haemorrhage in both age groups. These data provide evidence that soon after birth, glomerular and tubular responses to severe blood loss are elicited, though they do not appear to be developmentally regulated.[Supported by the Canadian Institutes of Health Research.]

Prohemostatic Interventions in Trauma: Resuscitation-Associated Coagulopathy, Acute Traumatic Coagulopathy, Hemostatic Resuscitation, and Other Hemostatic Interventions

Trauma is the most common cause of death in the young and hemorrhage is the most important cause of death in patients with trauma. Recently redefined pathways of inflammation and coagulation, together with hypothermia and acidosis contribute to trauma-associated coagulopathy and aggravation of bleeding. Pharmacological prohemostatic agents may be useful to (partly) correct the coagulopathy in trauma patients and may serve as useful adjunctive treatment options in patients with severe blood loss after trauma. Recombinant factor VIIa, fibrinogen and prothrombin complex concentrates, and antifibrinolytic agents have been evaluated in clinical trials. These interventions show promising effects but their efficacy in reducing clinically important outcome parameters need to be confirmed in clinical studies.

Postpartum Hemorrhage Resulting From Uterine Atony After Vaginal Delivery

OBJECTIVE: To identify factors associated with severity of postpartum hemorrhage among characteristics of women and their delivery, the components of initial postpartum hemorrhage management, and the organizational characteristics of maternity units. METHODS: This population-based cohort study included women with postpartum hemorrhage due to uterine atony after vaginal delivery in 106 French hospitals between December 2004 and November 2006 (N=4,550). Severe postpartum hemorrhage was defined by a peripartum change in hemoglobin of 4 g/dL or more. A multivariable logistic model was used to identify factors independently associated with postpartum hemorrhage severity. RESULTS: Severe postpartum hemorrhage occurred in 952 women (20.9%). In women with postpartum hemorrhage, factors independently associated with severity were: primiparity; previous postpartum hemorrhage; previous cesarean delivery; cervical ripening; prolonged labor; and episiotomy; and delay in initial care for postpartum hemorrhage. Also associated with severity was 1) administration of oxytocin more than 10 minutes after postpartum hemorrhage diagnosis: 10-20 minutes after, proportion with severe postpartum hemorrhage 24.6% compared with 20.5%, adjusted OR 1.38, 95% CI 1.03-1.85; more than 20 minutes after, 31.8% compared with 20.5%, adjusted OR 1.86, CI 1.45-2.38; 2) manual examination of the uterine cavity more than 20 minutes after (proportion with severe postpartum hemorrhage 28.2% versus 20.7%, adjusted OR 1.83, 95% CI 1.42-2.35); 3) call for additional assistance more than 10 minutes after (proportion with severe postpartum hemorrhage 29.8% versus 24.8%, adjusted OR 1.61, 95% CI 1.23-2.12 for an obstetrician, and 35.1% compared with 29.9%, adjusted OR 1.51, 95% CI 1.14-2.00 for an anesthesiologist); 4) and delivery in a public non-university hospital. Epidural analgesia was found to be a protective factor against severe blood loss in women with postpartum hemorrhage. CONCLUSION: Aspects of labor, delivery, and their management; delay in initial care; and place of delivery are independent risk factors for severe blood loss in women with postpartum hemorrhage caused by atony.

Safety of Prohemostatic Interventions

Pharmacological prohemostatic agents may be useful adjunctive treatment options in patients with severe blood loss. The efficacy of these interventions has been established in a variety of clinical situations. However, the procoagulant effect of these interventions may tip the balance toward a higher risk of thrombotic complications. Several studies have shown that some prohemostatic interventions may indeed increase the risk of arterial and venous thromboembolism, although these complications are relatively rare. When considering the use of adjunctive prohemostatic agents to prevent or treat excessive blood loss, the risk of thrombotic complications should be taken into account.

Ghrelin attenuates brain injury after traumatic brain injury and uncontrolled hemorrhagic shock in rats.

Traumatic brain injury (TBI) and hemorrhagic shock often occur concomitantly due to multiple injuries. Gastrointestinal dysfunction occurs frequently in patients with TBI. However, whether alterations in the gastrointestinal system are involved in modulating neuronal damage and recovery after TBI is largely neglected. Ghrelin is a "gut-brain" hormone with multiple functions including antiinflammation and antiapoptosis. The purpose of this study was to determine whether ghrelin attenuates brain injury in a rat model of TBI and uncontrolled hemorrhage (UH). To study this, brain injury was induced by dropping a 450-g weight from 1.5 m onto a steel helmet attached to the skull of male adult rats. Immediately after TBI, a midline laparotomy was performed and both lumbar veins were isolated and severed at the junction with the vena cava. At 45 min after TBI/UH, ghrelin (4, 8 or 16 nmol/rat) or 1 mL normal saline (vehicle) was intravenously administered. Brain levels of TNF-α and IL-6, and cleaved PARP-1 levels in the cortex were measured at 4 h after TBI/UH. Beam balance test, forelimb placing test and hindlimb placing test were used to assess sensorimotor and reflex function. In additional groups of animals, ghrelin (16 nmol/rat) or vehicle was subcutaneously (s.c.) administered daily for 10 d after TBI/UH. The animals were monitored for 28 d to record body weight changes, neurological severity scale and survival. Our results showed that ghrelin downregulated brain levels of TNF-α and IL-6, reduced cortical levels of cleaved PARP-1, improved sensorimotor and reflex functions, and decreased mortality after TBI/UH. Thus, ghrelin has a great potential to be further developed as an effective resuscitation approach for the trauma victims with brain injury and severe blood loss.

Association Between Bleeding Severity and Long-Term Mortality in Patients Experiencing Vascular Complications After Percutaneous Coronary Intervention

Vascular complications (VCs) occur in 3% to 8% of percutaneous coronary interventions (PCIs). However, only a portion of patients who experience VCs bleed significantly. The aim of this study was to assess the covariates associated with the amount of blood loss in patients experiencing postprocedural VCs as well as the effect of the degree of blood loss on long-term mortality. Overall, 7,718 unselected patients who underwent PCI through femoral access were evaluated. Those experiencing VCs were identified and stratified with regard to the degree of hematocrit (HCT) decrease after the procedure. In total, 444 patients (5.8%) had VCs. Compared to those without VCs, patients with VCs were older and had more extensive co-morbidities. Severe blood loss was most frequent in those who had vascular perforation requiring surgical repair or in those who had retroperitoneal bleeding. Overall, <25% of patients with hematoma had severe blood loss. The raw 1-year mortality was doubled in patients with minimal or moderate HCT decrease and was tripled in those with severe decreases in HCT. Similarly, the rate of definite stent thrombosis was tripled in patients with VCs and moderate or severe decreases in HCT. After adjustment, only patients with VCs and the greater HCT decreases had an increased risk for death at 1 year (hazard ratio 1.80, 95% confidence interval 1.03 to 3.14). Independent predictors of severe HCT decrease included age, female gender, glycoprotein IIb/IIIa inhibitor use, and activated clotting time peak. Bivalirudin and closure devices were independently associated with less frequent severe HCT decrease. In conclusion, VCs do not entail an increased risk for death at 1 year unless associated with severe blood loss. The use of bivalirudin and closure devices seems to reduce the risk for such complications.