Treatment Of Severe Hemorrhage Research Articles

Necessity of repeated renal arteriography in the treatment of severe hemorrhage after percutaneous nephrolithotomy

In order to discuss the necessity of repeated renal arteriography in the treatment of severe bleeding after percutaneous nephrolithotomy, this study retrospectively analyzed the clinical data of patients with severe bleeding after percutaneous nephrolithotomy in the Department of Urology Surgery of the First Hospital of China Medical University from August 2010 to July 2020, summarily analyzing treatments, outcomes and follow-up results of 27 patients who were treated by renal arteriography more than twice. Of these 27 patients who underwent repeated renal arteriography, 23 of them were treated by two times, 4 by three times, all of whom were diagnosed as renal vascular injury. And 15 of them were diagnosed as pseudoaneurysm, 4 of them renal arteriovenous fistula, and 8 of them pseudoaneurysm combined with renal arteriovenous fistula. After clear diagnosis, all these patients were performed with renal artery embolization, after which the symptoms of hematuria and lumbar discomfort were relieved or disappeared immediately. These patients were followed up from 6 months to 5 years, without corresponding symptoms recurring and with the renal function equivalent to that before embolization. The results showed that repeated renal arteriography was of great significance in the treatment of patients with severe bleeding after percutaneous nephrolithotomy, helping to clarify the cause of bleeding and giving appropriate and timely treatment.

Zastosowanie laseroterapii i rVIIa w leczeniu krwawienia do tkanek miękkich w trombastenii Glanzmanna

Glanzmann’s thrombasthenia (GT) is a rare thrombocytopathy. It is an autosomal recessive disorder. This disease is caused by the quantitative or qualitative defect of the αIIbβ3 membrane integrin, which is the receptor binding the adhesion proteins to the platelet surface in the initial stage of the coagulation process. Abnormal platelet aggregation associated with the αIIbβ3 mutation is the cause of serious and challenging bleeding. The first-line treatment for severe bleeding is transfusion of platelet concentrate or recombinant factor VIIa (rFVIIa) in case of refractoriness to transfusion. The primary objective of this study was to describe clinical effects observed in laser treatment of muscle bleeding in patients with coagulation disorders. We present the case of a 13-year-old boy with TG who was admitted to the hospital with quadriceps muscle hematoma after falling from the bicycle. Due to the lack of response to a platlet concentrate we used rFVIIa with a good effect. Due to the presence of a large painful muscle hematoma, we started laser therapy. Significant pain reduction and rapid hematoma regression were observed.

Experience in the treatment of severe bleeding in Crohn’s disease with anti-TNF therapy

Experience in the treatment of severe bleeding in Crohn’s disease with anti-TNF therapy

Platelets loaded with liposome‐encapsulated thrombin have increased coagulability

Background Platelets are integral to clot formation and are often transfused to stop or prevent bleeding. However, transfusions of platelets are not always effective, particularly in the most severe cases of hemorrhage. Nanoparticle systems have been developed to mimic platelets but inherently lack important aspects of platelet function, which limits their potential effectiveness. Objectives Increasing the natural coagulability of transfusable platelets could increase their efficacy during treatment of severe hemorrhage. Thrombin is a potent platelet agonist that currently cannot be used intravenously because of the risk of thrombosis. We hypothesized that delivery of thrombin to ex vivo platelets via liposomal encapsulation would enable transfusable platelets to become more coagulable in response to platelet agonists. Methods Thrombin was encapsulated into nanoliposomes and delivered to platelets ex vivo. Platelet coagulability was measured by monitoring platelet activation, clot contraction, clot time and clot stability in several in vitro assays. These parameters were also measured under conditions where coagulation is compromised, including during acidosis, antiplatelet drugs, hemophilia A and trauma-induced coagulopathy. Results Liposomal thrombin was endocytosed and used by platelets ex vivo but was not secreted upon activation. These modified platelets became more sensitive and responsive to agonists and improved clotting time even under conditions that normally cause platelet dysfunction or have impaired coagulation. Conclusions Several aspects of platelet function were enhanced by ex vivo delivery of liposomal thrombin.

Cell therapy for diverse central nervous system disorders: inherited metabolic diseases and autism.

The concept of utilizing human cells for the treatment of medical conditions is not new. In its simplest form, blood product transfusion as treatment of severe hemorrhage has been practiced since the 1800s. The advent of hematopoietic stem cell transplantation (HSCT) began with the development of bone marrow transplantation for hematological malignancies in the mid-1900s and is now the standard of care for many hematological disorders. In the past few decades, HSCT has expanded to additional sources of donor cells, a wider range of indications, and the development of novel cell products. This trajectory has sparked a rapidly growing interest in the pursuit of innovative cell therapies to treat presently incurable diseases, including neurological conditions. HSCT is currently an established therapy for certain neurologically devastating inherited metabolic diseases, in which engrafting donor cells provide lifelong enzyme replacement that prevents neurological deterioration and significantly extends the lives of affected children. Knowledge gained from the treatment of these rare conditions has led to refinement of the indications and timing of HSCT, the study of additional cellular products and techniques to address its limitations, and the investigation of cellular therapies without transplantation to treat more common neurological conditions, such as autism spectrum disorder.

Implementation of massive transfusion protocol (MTP) for trauma

Introduction Massive transfusion, the administration of 10 or more units of packed red blood cells (RBC) in less than 24 hours, can be a lifesaving therapy in the treatment of severe bleeding following injury. The rapid delivery and administration of large numbers of Packed Red Blood cells (PRBC), along with sufficient plasma and platelets is frequently a disorderly process. Establishment of MTP addresses this issue and has shown to reduce mortality and reduce the effects of coagulopathy associated with trauma. Methods Following a preliminary discussion with all the stake holders including the administrators, we implemented a protocol which supports the ratio of 1:1:1, of PRBC: FFP(Fresh Frozen Plasma) : Platelet. Each step of the process, from activation of protocol to termination was defined. The contents of boxes 1, 2 and 3 were Predetermined. Conclusion We hope to encourage the use of MTP in other centres in the country to achieve better results with post-trauma bleeding patients. The effectivenes of implementing such a protocol depends on the understanding and collaboration of each member responsible. The Sri Lanka Journal of Surgery 2015; 33(2): 3-7

Diagnostic evaluation of our patients with hemophilia A: 17-year experience.

Hemophilia A is a rare inherited bleeding disorder resulting from factor VIII deficiency and is a group of diseases characterized by intra-articular and intramuscular bleeding. In this study, we aimed to retrospectively evaluate the treatment outcomes, demographic and clinical characteristics of our patients who were treated and followed up for last 17 years in our pediatric hematology unit with a diagnosis of Hemophilia A. The medical records of 83 patients who were diagnosed with Hemophilia A and followed up between 1997 and 2014 in our hospital's pediatric hematology clinic were reviewed retrospectively. The demographic data, prophylaxis state, development of inhibitors and clinical characteristics of the patients were evaluated. When the complaints at presentation were examined, it was found that 27 (32%) patients had hemarthrosis, 24 (29%) patients had ecchymosis and hematoma, 13 (16%) patients had prolonged bleeding after trauma or cut, 10 (12%) patients had gingival, mouth or nose bleeding, 4 (5%) patients had prolonged bleeding after circumcision, 4 (5%) patients had gastrointestinal bleeding, 1 (1%) patient had hematuria. Fifty (60%) patients were considered severe hemophilia A, 20 (24%) patients were considered moderate hemophilia A and 13 (16%) patients were considered mild hemophilia A according to factor activity. Among severe hemophilia A patients, primary prophylaxis was being administered in 2 (2%) patients and secondary prophylaxis was being administered in 40 (48%) patients. Inhibitor positivity was found in 8 (10%) of these patients. It is found that hemophilic artropathy developed in 17 patients and 8 of these 17 patients had undergone radioisotope synovectomy. Treatment of severe bleeding in hemophilia A patients should be performed in hospital and the presence of inhibitor must be investigated in cases of uncontrolled bleeding where adequate doses of factor concentrates have been administered for treatment. In order to decrease the development of inhibitor, prophlaxis should be suggested to patients rather than repetetive treatment when bleeding occurs. The radioactive synovectomy should not be overlooked in countries like ours in which factors can not be used adequately.

Emergency Use of Intravenous Phytonadione (Vitamin K1) for Treatment of Severe Bleeding in a Child With Chronic Cholestasis

We present a 5-year-old boy with multiple hematomas associated with chronic cholestasis. A week before admission he suffered minor trauma at day care. The next day he complained of trunk and limb pain and orthopedic consultation, including leg x-rays, revealed no abnormalities. Over the next 5 days multiple hematomas developed over his body and increased in size. In the Emergency Department he was in pain and looked sick but alert. He had fever and tachycardia, with normal blood pressure and respiratory status and physical examination showed several hematomas on the legs, which increased in size during observation in the Emergency Department over 2 hours. Blood work revealed multiple coagulation abnormalities, and International Normalized Ratio was 12. Intravenous phytonadione (vitamin K1) was immediately administered with normalization of coagulation abnormalities within 1 hour and the hematomas stopped growing in size. In addition to missing follow-up with the Pediatric Gastroenterology Department, social service agency inquiry found he had not taken his medications for several months. With severe abnormal bleeding and hepatic disease, intravenous vitamin K1 may be lifesaving, even before obtaining confirmatory blood work, fresh-frozen plasma, or blood transfusion.

Fibrinogen Supplementation in Cardiac Surgery: Where Are We Now and Where Are We Going?

Fibrinogen Supplementation in Cardiac Surgery: Where Are We Now and Where Are We Going?

Thrombotic Endotracheal Tube Occlusion After Administration of Recombinant Factor VIIa

RECOMBINANT HUMAN FACTOR VIIa (rFVIIa) promotes hemostasis by interacting with both the extrinsic and intrinsic pathways of the coagulation cascade.1 Although rFVIIa may be very effective in the treatment of severe bleeding after cardiac surgery, its cost and potential to cause major thrombotic complications have limited its use. Data describing thrombotic events associated with rFVIIa are scarce, and there is a debate as to the role of rFVIIa after cardiac surgery.2-4 A case in which the administration of rFVIIa for persistent bleeding after cardiopulmonary bypass (CPB) in a child was followed by repeated, complete thrombotic occlusion of the endotracheal tube (ETT) is presented.

Use of Recombinant Factor Seven (rFVIIa) in the treatment of severe bleeding from trauma

No abstract available. DOI: http://dx.doi.org/10.4038/sljs.v30i1.4499 The Sri Lanka Journal of Surgery 2012; 30(1):9-12

Treatment for severe bleeding.

It has been estimated that about half of all major trauma patients die in hospital. Of these, nearly one third die due to excessive blood loss and most others die from injuries that are worsened by bleeding.

Fibrinogen concentrate in the treatment of severe bleeding after aortic aneurysm graft surgery

Aortic aneurysm graft surgery involving cardiopulmonary bypass is often associated with substantial coagulopathic perioperative bleeding, requiring hemostatic intervention with allogeneic blood products, such as fresh frozen plasma, platelet concentrate, and red blood cells. We conducted a pilot study to determine the effects of fibrinogen concentrate in patients with microvascular bleeding during aortic valve surgery with ascending aorta replacement. Dosing of fibrinogen concentrate was individualized based on thromboelastometry. First-line therapy with fibrinogen concentrate reduced the need for allogeneic blood product support, including transfusions of fresh frozen plasma, platelet concentrate, and red blood cells. Similar results were seen in a second cohort study conducted in patients undergoing thoraco-abdominal aortic aneurysm surgery: patients who received fibrinogen concentrate required significantly less allogeneic blood product support following surgery. These results prompted the initiation of a randomized placebo-controlled trial in patients undergoing thoraco-abdominal aortic aneurysm surgery, aortic valve surgery with ascending aorta replacement, or aortic arch surgery. Results are expected to be published soon. Larger, multicenter studies are needed to determine the exact role of fibrinogen concentrate in the management of perioperative bleeding following cardiac surgery and cardiopulmonary bypass.

High Flow Nasal Prongs Use in the Post-cardiac Surgical Population Increases Functional Residual Capacity, Improves Oxygenation and Reduces Work of Breathing

with ‘high’ dose therapy. Patients in each dose category did not demonstrate clinically meaningful differences on measures of acuity, transfusion requirements or prior medications. Results demonstrated no significant differences in the rate of thromboembolic adverse events, response to bleeding or 28-day mortality (Table 1). Discussion: These findings raise the important question of whether lower doses of rFVIIa may be as effective and efficacious as higher doses in the treatment of severe bleeding in cardiac surgery patients. doi:10.1016/j.hlc.2010.10.020 High Flow Nasal Prongs Use in the Post-cardiac Surgical Population Increases Functional Residual Capacity, Improves Oxygenation and Reduces Work of Breathing J.F. Fraser 1,∗, A. Corley1, A.G. Barnett 2, L. Caruana1, O. Tronstad1 1 Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia 2 Institute ofHealth&Biomedical Innovation,QueenslandUniversity of Technology, Brisbane, Australia Introduction: Hypoventilation, lobar collapse and atelectasis are not uncommon after cardiac surgery and may result inprolonged invasiveandnon-invasiveventilation together with the incipient ICU costs. High flow nasal p t i E w c

A time to remember

A time to remember

Effects of fibrinogen concentrate administration during severe hemorrhage

Fibrinogen concentrate has been shown to improve coagulation in dilutional coagulopathy in experimental studies, but clinical experience is still scarce. The aim of this study was to evaluate laboratory data and the clinical outcome of fibrinogen administration in patients suffering from severe hemorrhage. A retrospective study over a 3-year observation period of consecutive patients who received a single dose of fibrinogen concentrate but not recombinant factor VIIa as part of their treatment of severe hemorrhage, defined as >6 U of packed red blood cells (PRBCs). Thirty-seven patients were included, most of them suffering from severe hemorrhage following open heart surgery (68%). After a median fibrinogen dose of 2 g (range 1-6 g), an absolute increase in the plasma fibrinogen concentration of 0.6 g/l was observed (P<0.001). The activated partial thromboplastin time (APTT) decreased significantly (P<0.001), from 52 to 43 s and the prothrombin time (PT) decreased from 20 to 17 s, respectively. The transfusion requirement for PRBCs decreased from 6 to 3 U (P<0.01) in the 24 h after fibrinogen administration, but fresh-frozen plasma and platelet concentrate transfusions did not change significantly. Eight patients (22%) died in intensive care unit and the pre-operative fibrinogen concentration was not significantly different in these patients. Administration of fibrinogen for severe hemorrhage was associated with an increased fibrinogen concentration and a significant decrease in APTT, PT and the requirement for PRBCs.

Implantation of self-expanding metal stent in the treatment of severe bleeding from esophageal ulcer after endoscopic band ligation

Endoscopic variceal ligation is superior to sclerotherapy because of its lower rebleeding and complication rates. However, ligation may be associated with life-threatening bleeding from postbanding esophageal ulcer. We report a case of a 49-year-old male with massive hemorrhage from esophageal ulcer on 8th day after successful band ligation of bleeding esophageal varices caused by postviral liver cirrhosis (Child-Pugh class C). A removable polyurethane membrane-covered self-expanding metal stent (SX-ELLA stent Danis, 135 mm × 25 mm, ELLA-CS, Hradec-Kralove, Czech Republic) was inserted in ICU for preventing fatal hemorrhage. Complete hemostasis was achieved and stent was removed after 8 days without rebleeding or any complications. To the best of our knowledge, this is the first report in English literature regarding life-threatening hemorrhage from postbanding esophageal ulcer successfully treated by self-expanding metal stent in a patient with portal hypertension.

Prothrombin complex concentrate in surgical patients: retrospective evaluation of vitamin K antagonist reversal and treatment of severe bleeding

IntroductionProthrombin complex concentrates are recommended for rapid reversal of vitamin K anticoagulants. As they normalize levels of vitamin K dependent clotting factors and re-establish hemostasis, they may also be used as adjunctive therapy in patients with major bleeding. The aim of this study was to retrospectively evaluate the efficacy of prothrombin complex concentrates in the surgical setting.MethodsThe case notes of 50 patients requiring urgent oral anticoagulation reversal (n = 12) or with severe perioperative coagulopathic bleeding (n = 38) who received an infusion of prothrombin complex concentrate (Beriplex P/N(R) 500) at the surgical department of the University of Munich Hospital, Germany were retrospectively reviewed. Efficacy of prothrombin complex concentrate application was evaluated using the Quick test, reported as an international normalized ratio, hemodynamic measurements and requirement for blood products. Safety assessments included whole blood hemoglobin levels and specific parameters of organ dysfunction.ResultsBaseline characteristics were comparable, except that mean baseline international normalized ratio and hemoglobin levels were significantly higher (P < 0.01) in anticoagulation reversal than in bleeding patients. In anticoagulation reversal, the international normalized ratio was significantly reduced (from 2.8 +/- 0.2 at baseline to 1.5 +/- 0.1, P < 0.001) after one prothrombin complex concentrate infusion (median dose 1500 IU; lower quartile 1,000, upper quartile 2,000). No major bleeding was observed during surgery after prothrombin complex concentrate administration. Only one patient received platelets and red blood cell transfusion after prothrombin complex concentrate administration. In bleeding patients, infusion of prothrombin complex concentrate (median dose 2,000 IU; lower quartile 2,000, upper quartile 3,000) significantly reduced the INR from 1.7 +/- 0.1 at baseline to 1.4 +/- 0.1 (P < 0.001). This decrease was unrelated to fresh frozen plasma or vitamin K administration. Bleeding stopped after prothrombin complex concentrate administration in 4/11 (36%) patients with surgical bleeding and 26/27 (96%) patients with diffuse bleeding. Hemoglobin levels increased significantly from baseline in bleeding patients (P < 0.05) and mean arterial pressure stabilized (P < 0.05). No thrombotic events or changes in organ function were reported in any patient.ConclusionsProthrombin complex concentrate application effectively reduced international normalized ratios in anticoagulation reversal, allowing surgical procedures and interventions without major bleeding. In bleeding patients, the improvement in coagulation after prothrombin complex concentrate administration was judged to be clinically significant.

Recombinant Factor VIIa

Uncontrolled bleeding and coagulopathy are associated with trauma, liver failure, obstetric conditions, and a variety of surgical circumstances, resulting in increased morbidity and mortality in the critically ill. Recently, the role of recombinant factor VIIa (rFVIIa) in the management of uncontrolled bleeding has attracted interest. rFVIIa was initially developed (and licensed) for the treatment of hemophilia. Increasingly, evidence suggests rFVIIa causes cessation of bleeding, improves coagulation markers, and reduces blood product use for treatment of severe bleeding due to other causes. The majority of evidence for nonlicensed use of rFVIIa consists of case reports. Recently, the first randomized controlled trial of rFVIIa in trauma patients reported a significant reduction in red blood cell transfusion, and a trend toward reduced mortality and critical complications. As evidence builds to support the use of rFVIIa, nurses need to be aware of the administration and safety issues of this treatment.

Recombinant activated factor VII treatment of severe bleeding in cardiac surgery patients: a retrospective analysis of dosing, and efficacy and safety outcomes

This study describes patient characteristics, recombinant activated factor VII (RF7a) dosing and clinical outcomes of cardiovascular surgery patients treated with RF7a for intractable bleeding. Use of RF7a for postsurgical bleeding, trauma or other uses in non-hemophiliac patients is considered off-label in the USA. Comprehensive studies evaluating RF7a in cardiac surgery patients are limited. Published reports cite success with RF7a administration in massive intractable bleeding. However, patient selection, dosing, efficacy, safety and pharmacoeconomic benefit remain undefined. Patients receiving RF7a between January 2004 and September 2005 were identified via pharmacy records. Clinical databases and electronic medical records were reviewed, collecting data elements needed to assess study objectives. One hundred and twenty patients were identified. Twenty-seven patients were excluded because they lacked documentation of RF7a administration, were treated for neurologic indications or had incomplete medical record data. Ninety-three patients were analyzed. RF7a effectively achieves hemostasis in patients with intractable bleeding, reducing blood product transfusions within 6 hours of treatment (Figure ​(Figure1).1). Our findings suggest differences in PRBC transfusion reduction between RF7a doses. We observed no additional reduction PRBC transfusions in patients administered doses greater than 60–90 μg/kg (Figure ​(Figure2).2). Effects of RF7a on surgical re-exploration and other potential related adverse events (stroke, AMI, VTE, etc.) are forthcoming. Our study, like others evaluating RF7a for this indication, are limited by the retrospective scope. Randomized trials comparing RF7a doses are under way. Although RF7a therapy is costly, minimal reductions in surgical re-exploration may offset the cost of RF7a therapy provided that adverse events are not increased. Figure 1 Figure 2