Use Of Cryoprecipitate Research Articles

Update on massive transfusion

Massive haemorrhage requires massive transfusion (MT) to maintain adequate circulation and haemostasis. For optimal management of massively bleeding patients, regardless of aetiology (trauma, obstetrical, surgical), effective preparation and communication between transfusion and other laboratory services and clinical teams are essential. A well-defined MT protocol is a valuable tool to delineate how blood products are ordered, prepared, and delivered; determine laboratory algorithms to use as transfusion guidelines; and outline duties and facilitate communication between involved personnel. In MT patients, it is crucial to practice damage control resuscitation and to administer blood products early in the resuscitation. Trauma patients are often admitted with early trauma-induced coagulopathy (ETIC), which is associated with mortality; the aetiology of ETIC is likely multifactorial. Current data support that trauma patients treated with higher ratios of plasma and platelet to red blood cell transfusions have improved outcomes, but further clinical investigation is needed. Additionally, tranexamic acid has been shown to decrease the mortality in trauma patients requiring MT. Greater use of cryoprecipitate or fibrinogen concentrate might be beneficial in MT patients from obstetrical causes. The risks and benefits for other therapies (prothrombin complex concentrate, recombinant activated factor VII, or whole blood) are not clearly defined in MT patients. Throughout the resuscitation, the patient should be closely monitored and both metabolic and coagulation abnormalities corrected. Further studies are needed to clarify the optimal ratios of blood products, treatment based on underlying clinical disorder, use of alternative therapies, and integration of laboratory testing results in the management of massively bleeding patients.

Effective Reduction of Blood Product Use in a Community Teaching Hospital: When Less Is More

BackgroundThe increased morbidity and mortality associated with liberal blood product usage have been convincingly demonstrated. The clinical problems they pose have prompted development of more restrictive evidence-based transfusion criteria. Education alone has a limited impact on the adoption of these criteria into practice. New York Methodist Hospital undertook a proactive approach to reduce unnecessary transfusions. MethodIn November 2008, an interventional monitoring program to ensure adherence to transfusion criteria for packed red blood cells (PRBC), platelets, fresh frozen plasma (FFP), and cryoprecipitate transfusions was started. Blood bank technologists routinely monitored transfusion requests against a list of established criteria and experienced clinicians reviewed and adjudicated transfusion requests when the blood bank technologist's action was appealed. ResultsTransfusion usage decreased sharply in Year 1 (November 2008-October 2009) and continued to decrease in Year 2 (November 2009-October 2010). PRBC use decreased by 30.1% and 37.7%, with a 47.6% decrease in multi-unit transfusions; platelet use decreased by 24.3% and 41.2%; fresh frozen plasma use decreased by 41.8% and 31.1%; and cryoprecipitate use decreased by 38.7% and 56.1% during monitoring Years 1 and 2, respectively. Decreases occurred despite a 4.0% increase in hospital admissions during the monitoring years. The decreased blood product usage was accompanied by 28.6% reduction in complications. A 26.1% decrease in blood product requests from Year 1 to Year 2 suggested a practice change by the ordering physicians themselves. The total cost of blood products decreased by $2,235,676. ConclusionWe established a successful method to reduce transfusions of all blood products using strict adherence to evidence-based criteria and continuous monitoring. Our model translates into improved patient safety by decreasing the number of unnecessary transfusions. This also led to a significant reduction in hospital expenses.

The management of critical bleeding in obstetrics

Post-partum hemorrhage (PPH) is one of the most frequent causes of maternal death: worldwide it contributes for a 25% of deaths. The risk of death from pregnancy complications has decreased dramatically over the last few decades, but several evidences show they have not yet been reduced to a minimum. There is therefore the need for a further improvement in the quality of medical care. Purpose of this paper is to briefly outline an overview of the definition of PPH, with an illustration of the possible causes and treatments currently available. WHO defined PPH as excessive bleeding > 500 ml after vaginal delivery and severe PPH as bleeding in excess of 1,000 ml after vaginal delivery, but a variety of definitions for PPH have been proposed, yet no single satisfactory definition exists. Another crucial item regards the estimation of blood loss, too often based on a visual assessment and, therefore, inaccurate and minimized. However, in medical literature there are no specific classifications for severe bleeding in obstetrics. During pregnancy there are several changes in coagulation state: because haemostatic reference intervals are generally based on samples from non-pregnant women, this can cause a further difficulty in doing an accurate diagnosis and treatment of haemostatic disorders during pregnancy. In the treatment of critical bleeding in trauma patients have been developed some new insights that may be applied, at least partially, in the management of bleeding patients in obstetrics. In recent years it has been developed an approach called “Damage control resuscitation”, which combines to the surgery a medical treatment aimed at correcting the underlying coagulopathy. This approach is based on three items: minimise use of crystalloids and colloids; optimise fresh frozen plasma (FFP) to red blood cells (RBC) ratio; make an appropriate use of antifibrinolitic agents, fibrinogen and cryoprecipitate.

When do we transfuse cryoprecipitate?

The 2001 National Health and Medical Research Council/Australasian Society of Blood Transfusion Clinical Practice Guidelines for cryoprecipitate are being updated, and cryoprecipitate has been incorporated into new Patient Blood Management modules. This clinical audit sought to clarify current cryoprecipitate use in Victoria, Tasmania and the Australian Capital Territory; assess adherence to guidelines; and gain insights into deviations from recommended practice. This information can be utilised in updating guidelines to make them more relevant, to identify areas for clinician education and to form a baseline of practice prior to release of the 2011 guidelines. Participating institutions were invited to audit up to 30 consecutive episodes of cryoprecipitate transfusion over an 11-month period in 2008. The audits were conducted using a standardised pro forma and involved review of patient records. These were collated electronically using algorithms to determine alignment versus non-alignment with guidelines. Cryoprecipitate is used in a variety of situations with surgery accounting for the highest volume. Twenty-six per cent (26%) of transfusions were aligned with 2001 guidelines rising to 61% with a modified fibrinogen trigger. Fibrinogen levels did not appear to dictate all clinical decisions regarding cryoprecipitate use perhaps owing to the acuity of many cases. Additional bleeding risk together with low fibrinogen levels (e.g. thrombocytopenic patients) may contribute to empiric cryoprecipitate use. These results highlight discrepancies between guidelines and practice, providing rationale for the update of the guidelines that is currently underway. Cryoprecipitate has attendant risks, and it is appropriate that transfusion be restricted to situations with good evidence or sound principles to underpin use.

Cryoprecipitate use in the PROMMTT study

There are few clinical data to guide the use of cryoprecipitate in severely injured trauma patients. Cryoprecipitate is a rich source of fibrinogen and has been associated with improved survival in animal as well as limited human studies. Our objectives were to identify patterns and predictors of cryoprecipitate use and determine whether transfusing cryoprecipitate was associated with improved survival. This secondary analysis of 1,238 of 1,245 PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study patients who had timed transfusion data included 359 (29%) who received cryoprecipitate. For this analysis, one dose of cryoprecipitate was defined as 10 U. Unadjusted predictors of cryoprecipitate use were identified using logistic regression. Multivariable time-dependent Cox models were performed to examine the association of cryoprecipitate on time to in-hospital death. Cryoprecipitate use varied significantly by center, ranging from 7% to 82%. Among patients who received cryoprecipitate, the median number of units infused by 24 hours was 10 (interquartile range, 10-20). The median time from admission to first cryoprecipitate unit was 2.7 hours (interquartile range, 1.7-4.4 hours). Of those who died of a hemorrhagic death within 6 hours of admission, 72% received no cryoprecipitate. Other unadjusted predictors of cryoprecipitate use included Injury Severity Score (ISS), initial fibrinogen levels, base deficit, international normalized ratio, prothrombin time/partial thromboplastin time, hemoglobin, damage-control surgery, and surgical intervention of the chest and abdomen. Cryoprecipitate use was not associated with in-hospital mortality after adjusting for initial pH, initial hemoglobin, emergency department systolic blood pressure, emergency department Glasgow Coma Scale (GCS) score, blood product use, ISS, and center. Ten US Level 1 trauma centers vary greatly in their timing and use of cryoprecipitate in severely injured trauma patients. We could not identify any association of cryoprecipitate use with in-hospital mortality, although most patients did not receive this product. Randomized controlled studies are needed to determine if cryoprecipitate (or fibrinogen concentrates) have a beneficial effect.

Restoring hemostasis: fibrinogen concentrate versus cryoprecipitate

Fibrinogen plays a key role in the coagulation process, and therefore maintaining adequate quantities of fibrinogen is an essential step in achieving satisfactory hemostasis in patients with acquired hypofibrinogenemia. Potential options for treating acquired hypofibrinogenemia in patients with uncontrolled bleeding include the use of cryoprecipitate or fibrinogen replacement therapy. This review provides a brief overview of the hemostatic process and the methods for assessing coagulopathy and discusses the efficacy and safety of cryoprecipitate and fibrinogen concentrate in restoring fibrinogen levels, achieving hemostasis and reducing transfusion requirements in different patient populations requiring rapid hemostasis. Other issues relevant to the clinical use of these agents in restoring hemostasis, including variations in product composition, preparation time and cost, are also examined.

ADAMTS-13 contents in therapeutic plasma products

Background ADAMTS-13 is a zinc-containing metalloprotease enzyme that cleaves the von Willebrand factor (VWF). In human beings, changes in ADAMTS-13 levels have been observed in a number of diseases. The determination of ADAMTS-13 levels and those of its substrate will help to elucidate therapeutic strategies including ADAMTS-13 supplementation for these diseases. Successful treatment has been reported with both fresh-frozen plasma and cryoprecipitate poor plasma (CPP) as replacement fluids. This study aimed to investigate ADAMTS-13 and some coagulation factors in the different plasma products commonly used to increase ADAMTS-13 levels. Materials and methods A total of 180 U of whole blood (WB) were collected from healthy young male blood donors, their ages ranging from 20 to 32 years. Sixty donors were of blood type O+, 50 were A+, 50 were B+, and 20 were AB+. All blood donors included in this study underwent tests for assessment of their liver and kidney functions, and they were declared free from any disease. Plasma from the blood samples was extracted either on the day of collection (the platelet-rich plasma method) or after an overnight hold of WB (the Buffy coat method). Factor VIII (FVIII) activity was measured and levels of fibrinogen, VWF, and human ADAMTS-13 in plasma were quantitatively determined. Results There was no difference in the mean concentrations of ADAMTS-13 in plasma products obtained using the two different methods. Blood group O showed a higher concentration compared with other ABO blood groups. The concentration of ADAMTS-13 was higher in cryoprecipitate than in plasma and CPP. The mean values of FVIII activity were lower in many plasma and cryoprecipitate units prepared by overnight holding of WB for close to 24 h. In addition, the mean values of FVIII activities and VWF levels were lower in plasma and cryoprecipitate units prepared from blood group O compared with those prepared from other ABO blood groups. No differences were detected in the mean values of fibrinogen and VWF in the plasma products when different methods were used for preparation. Conclusion The observation that the concentration of ADAMTS-13 is higher in cryoprecipitate than in plasma and CPP suggests that cryoprecipitate may be a reasonable source of ADAMTS-13 in clinical settings when volume is an issue. In addition, in our study, the use of cryoprecipitate from blood group O in clinical settings yielded higher concentrations of ADAMTS-13 with less VWF. Although the use of cryoprecipitate instead of plasma or CPP could potentially double the amount of ADAMTS-13 infused, further studies from multiple centers are needed to validate the results.

It’s not your grandfather’s field plasma

Initiating prehospital resuscitation with plasma in patients with trauma-associated hemorrhagic shock will result in more rapid and durable clot formation and, thus, the need for fewer packed cell infusions, less frequent use of cryoprecipitate, and more ventilator-free hospital days compared with those of patients randomized to standard crystalloid field resuscitation.

The Monitoring of Serum Fibrinogen in Patients with End Stage Renal Disease Undergoing Plasma Exchange for High Risk Kidney Transplantation

Background: Plasma exchange is being increasingly used in the antibody reduction for high risk kidney transplantation. There were some reports of post-transplant bleeding in patients who had a large number of plasma exchange. In addition, wide variation in technique is reported, thereby adding to the confusion that exists about both efficacy and safety. Since changes in coagulation factors are known to occur to following plasmapheresis, we studied serial changes of serum fibrinogen in patients undergoing plasma exchange for antibody reduction before high risk kidney transplantation. Methods: Eighty eight times of plasma exchange were carried out at every other day in 18 patients before kidney transplantation, using the COBE® Spectra™ apheresis system. Sixteen patients were received ABO incompatible living donor kidney transplantation and 2 patients were received cross matching positive living donor kidney transplantation in our hospital from 2009 to 2011. The levels of serum fibrinogen were measured at pre-exchange, post-exchange one day and two days. In procedure, 1.0 time the calculated plasma volume was replaced with an electrolyte solution containing 5% salt-free human albumin or fresh frozen plasma (FFP). Anticoagulation was achieved using a whole venous blood to acid-citrate dextrose ratio of 15 to 1. Median flow rates, plasma collection, and procedure times were respectively 80 ml/minute, 20 ml/ minute, 80 minutes in cases of 5% albumin solution replacement and 40 ml/minute, 20 ml/minute, 150 minutes in cases of FFP replacement. Results: The cases with 5% albumin solution replacement were 55, and with FFP were 28. In cases of 5% albumin solution replacement, the mean serum fibrinogen level was 230.35 mg/dL, 138.93 mg/dL and 167.07 mg/dL at pre-exchage, post-exchage 1 day and post exchage 2 days. And in case of FFP replacement, the mean serum fibrinogen level was 168.68 mg/dL, 178.25 mg/dL and 181.18 mg/dL at the same time as before. The serum fibrinogen levels were markedly reduced immediately following the procedure and did not have returned to prior levels within 48 hours in cases of 5% albumin solution replacement. But the serum fibrinogen levels were increased in cases of FFP replacement.Table: [The serum fibrinogen levels in subjects(mg/dL).]Conclusion: In spite of every other day schedule, consecutive plasma exchange with 5% albumin solution replacement has a decrease of serum fibrinogen in patients with end stage renal disease before high risk kidney transplantation. And it may be associated with decrease coagulation and post-transplant bleeding. It is useful to prevent post-transplant bleeding that the use of FFP as replacement fluid or the use of cryoprecipitate containing fibrinogen and other coagulation factors.

Cryoprecipitate: an outmoded treatment?

Cryoprecipitate is an allogeneic blood product prepared from human plasma. It contains factors VIII, von Willebrand factor (vWF), fibrinogen, fibronectin and factor XIII. Its use was first described in the 1960s for treatment of patients with factor VIII deficiency. It has also been used to treat patients with congenital hypofibrinogenaemia. Now, the most common use of cryoprecipitate is fibrinogen replacement in patients with acquired hypofibrinogenaemia and bleeding. Despite almost 50 years of use, evidence of efficacy is limited. This review provides an overview of the history of cryoprecipitate use, the current debates on the use of this product and future developments.

Cryoprecipitate for transfusion: which patients receive it and why? A study of patterns of use across three regions in England

Despite increasing interest in the use of fibrinogen concentrates, cryoprecipitate remains the major source of fibrinogen in England. Understand patterns and indications for use of cryoprecipitate in hospitals from three English regions. Data collection over 3 months from adults, children and neonates receiving cryoprecipitate, including clinical scenario, indications, dose and levels of fibrinogen concentrations pre- and post-transfusion. Four hundred and twenty-three episodes of cryoprecipitate transfusion were analysed from 39 hospitals. Use varied from 0.1 to 4.9 units per 100 red cells transfused. The primary indication was haemorrhage [311 episodes (74%)]. The commonest clinical scenario in all age groups was cardiac surgery, followed by trauma in adults and critical/neonatal care for children. Pre-treatment fibrinogen levels were measured in 322 episodes. In 179 episodes, the level was ≥ 1.0 g L(-1) . Wide variation in practice and dose suggests inconsistent practice and uncertainty in the evidence informing optimal use of cryoprecipitate.

Bleeding in a Jehovah’s Witness patient undergoing a redo aortic valve replacement controlled with cryoprecipitate and a prothrombin complex concentrate

This is a case report involving a middle-aged Jehovah's Witness patient who underwent a redo aortic valve replacement, coronary artery bypass graft, and Maze procedure facilitated by cardiopulmonary bypass. The consent process included a discussion of the management of bleeding and hemostasis in the perioperative period in the context of the patients' religious choice and the possible consequences of avoiding transfusion in massive bleeding. The medical team agreed to abide by the patient's wishes with respect to the blood and blood products deemed unacceptable by the patient irrespective of the consequences. The consent included a discussion of manufactured hemostatic agents that are designated by the Hospital Liaison Committee Network for Jehovah's Witnesses as subject to personal decision. There was also a discussion of recombinant agents available, all of which are acceptable to Jehovah's Witness patients. The patient accepted the use of cryoprecipitate, prothrombin complex concentrate, and recombinant factor VIIa. After separation from cardiopulmonary bypass and protamine administration, blood loss was 350mL over a ten-minute period. The international normalized ratio (INR) was 3.5 at that time. Cryoprecipitate 15 U, 1-deamino-8-D-arginine vasopressin 16 U, and a prothrombin complex concentrate, Octaplex®, 60mL were administered. Blood loss improved significantly. The INR in the cardiac surgical intensive care unit was 1.3. The sample was taken approximately one hour following the administration of the hemostatic agents. The patient's chest was closed, and chest tube drainage was 310mL over the next 12 hr. This is a novel case involving the use of prothrombin complex concentrate in the setting of a Jehovah's Witness patient undergoing a complex operative procedure.

Clinical use of fresh-frozen plasma and cryoprecipitate in neonatal intensive care unit

Evidence-based indications for the use of plasma products in neonatal medicine are limited to few conditions. In the setting of inherited disorders of hemostasis, fresh frozen plasma (FFP) and cryoprecipitate should be used as replacement therapy only if the specific factor concentrate is not available. FFP is indicated to treat disseminated intravascular coagulation (DIC), liver failure, vitamin K-dependent bleeding and to reconstitute whole blood for exchange transfusion. Despite the lack of evidence, the use of cryoprecipitate to treat neonates with acquired hypofibrinogenemia during DIC or liver failure is now considered standard therapy.

Epidemiology, Diagnosis, and Management ofvon Willebrand Disease in India

Von Willebrand disease (VWD) in all developing countries including India is considered a rare coagulation disorder, contrary to many reports from Western countries. Prevalence data based on hospital referrals identifies type 3 VWD as the most common subtype followed by type 1 and type 2. Approximately 60 to 70% cases of type 3 VWD are reportedly born of consanguineous marriages. The discriminatory diagnostic tests mainly include assays for factor (F)VIII:C and ristocetin-induced platelet agglutination and Von Willebrand factor (VWF) antigen either by immunoelectrophoresis or by enzyme-linked immunosorbent assay. VWD-type assisting tests like VWF collagen binding, VWF ristocetin cofactor assay, VWF-FVIII binding assay, and multimer analysis are occasionally used but not routinely applied in many laboratories. Among women, menorrhagia is an important presenting manifestation. Except for a handful of centers mainly in metropolitan cities, most laboratories in the remote parts of the country have no facilities for VWD-related investigations, resulting in occasional misdiagnoses of VWD as hemophilia A. Genetic diagnosis is being offered in two or three centers using the indirect linkage method in type 3 VWD, and efforts are continuing to implementing a direct mutation detection technique for routine practice in a few laboratories. Depending on the subtype or the severity of VWD, desmopressin, cryoprecipitate, fresh-frozen plasma, and factor VIII/VWF concentrates are used for management. Antifibrinolytic agents like epsilon-aminocaproic acid and tranexamic acid are widely used as an adjuvant therapy. In women with menorrhagia, oral contraceptives as a supplementary treatment are also being widely advocated to reduce bleeding. Products like danazol, ethenyl estradiol, thalidomide, and atorvastatin have been used in individual patients; acquired VWD associated with hypothyroidism has been managed successfully with thyroid hormone treatment. Both minor and major surgical procedures are performed in a few centers with judicious use of cryoprecipitate or FVIII concentrate containing VWF along with other supplementary therapeutic products to achieve adequate hemostasis. Awareness about the disease, establishment of the comprehensive coagulation laboratory, and treatment centers will be successful in increasing diagnosis of VWD and consequently better management of affected patients. This is likely to tilt the ratios of different VWD types, and VWD is likely to emerge as the most common of all coagulation disorders in the near future.

A national study of plasma use in critical care: clinical indications, dose and effect on prothrombin time

IntroductionFresh frozen plasma (FFP) is widely used, but few studies have described patterns of plasma use in critical care. We carried out a multicentre study of coagulopathy in intensive care units (ICUs) and here describe overall FFP utilisation in adult critical care, the indications for transfusions, factors indicating the doses used and the effects of FFP use on coagulation.MethodsWe conducted a prospective, multicentre, observational study of all patients sequentially admitted to 29 adult UK general ICUs over 8 weeks. Daily data throughout ICU admission were collected concerning coagulation, relevant clinical outcomes (including bleeding), coagulopathy (defined as international normalised ratio (INR) >1.5, or equivalent prothrombin time (PT)), FFP and cryoprecipitate use and indications for transfusion.ResultsOf 1,923 admissions, 12.7% received FFP in the ICU during 404 FFP treatment episodes (1,212 FFP units). Overall, 0.63 FFP units/ICU admission were transfused (0.11 units/ICU day). Reasons for FFP transfusion were bleeding (48%), preprocedural prophylaxis (15%) and prophylaxis without planned procedure (36%). Overall, the median FFP dose was 10.8 ml kg-1, but doses varied widely (first to third quartile, 7.2 to 14.4 ml kg-1). Thirty-one percent of FFP treatments were to patients without PT prolongation, and 41% were to patients without recorded bleeding and only mildly deranged INR (<2.5). Higher volumes of FFP were administered when the indication was bleeding (median doses: bleeding 11.1 ml kg-1, preprocedural prophylaxis 9.8 ml kg-1, prophylaxis without procedure 8.9 ml kg-1; P = 0.009 across groups) and when the pretransfusion INR was higher (ranging from median dose 8.9 ml kg-1 at INR ≤1.5 to 15.7 ml kg-1 at INR >3; P < 0.001 across ranges). Regression analyses suggested bleeding was the strongest predictor of higher FFP dose. Pretransfusion INR was more frequently normal when the transfusion indication was bleeding. Overall, posttransfusion corrections of INR were consistently small unless the pretransfusion INR was >2.5, but administration during bleeding was associated with greater INR corrections.ConclusionsThere is wide variation in FFP use by ICU clinicians, and a high proportion of current FFP transfusions are of unproven clinical benefit. Better evidence from clinical trials could significantly alter patterns of use and modify current treatment costs.

Anaesthetic considerations during hepatic trauma surgery

The acute care of trauma patients poses unique challenges for both the anaesthesiologist and the surgeon. Current treatment concepts focus on the prevention of tissue ischaemia, rapid control of haemorrhage, haemostasis and maintenance of tissue perfusion. Successful resuscitation must also address the lethal triad: metabolic acidosis, coagulopathy and hypothermia, which characterize acute, fatal haemorrhagic shock, followed by circulatory system failure. The key elements include appropriate monitoring and mechanical and pharmacological protection of the vital organs to support the patient and restore perfusion. The goals for early resuscitation (prior to definitive control of haemorrhage) are: control of the airway and ventilation, expeditious control of haemorrhage maintaining a systolic blood pressure above 80 mmHg, limited use of crystalloid fluid and maintenance of haematocrit 25%–30%. The early use of plasma achieves normal clotting studies, and the possible use of cryoprecipitate and/or factor VIIa, if the patient is already coagulopathic, platelet count > 50000, stabilized core temperature of > 35°C and gradual conversion to deep general anaesthesia-analgesia are necessary. After the definitive control of haemorrhage, complete resuscitation is achieved by titrated administration of fluids until the following parameters are met: normal or hyperdynamic vital signs, haematocrit > 20%, normal serum electrolytes, normal coagulation function, Platelet count > 50000, restoration of adequate microvascular perfusion:-pH=7.40 with normal base deficit, normalized serum lactate, normal mixed venous oxygenation, normal or high cardiac output and normal urine output. The early management of patients who have major trauma and the prompt collaboration between the surgeon, the anaesthesiologist, the radiologist, the haematologist and the ICU can contribute to a positive outcome.

Effective Reduction of Blood Product Use In a Community Teaching Hospital: a Possible Interventional Model.

AbstractAbstract 1126▪ Background:The complications of blood transfusions and the increased morbidity and mortality associated with liberal use of blood products have been convincingly demonstrated. The clinical problems they pose have prompted development of evidence-based transfusion guidelines. Nevertheless, most hospitals do not enforce these guidelines and effective strategies have not been developed. Continuing medical education, such as conferences, do not appear to be effective in changing physician behavior, as confirmed in the literature and by our hospital's experience. New York Methodist Hospital therefore undertook a more proactive approach to reduce unnecessary transfusions and in the process to change physicians' attitude toward transfusions. Methods:In October 2008, our hospital implemented strict criteria for transfusions of all blood products including red blood cells (RBC), platelets, fresh frozen plasma, and cryoprecipitate. These criteria were applied by selected experienced clinicians who each served as monitors for their own clinical department. The blood bank required the approval of the monitor to release blood products that did not meet the criteria. This helped ensure that patients who indeed require transfusion based on clinical situation would be treated appropriately. Physicians had easy access to the monitors 24 hours a day, 365 days a year. Transfusion requests from operating rooms and post-anesthesia care units were excluded from monitoring. Transfusion of patients with active bleeding was also exempted because it was included in the RBC justification criteria. In most patients with symptomatic anemia, a single unit of RBC was approved. We compared data from the 12 months preceding (Year 1) and the 12 months after the enforcement of the criteria (Year 2). The data included the number of hospital admissions, the amount of blood products transfused per month, the type and number of transfusion-related complications, and the number of type and screens performed by the blood bank. Results:Transfusion usage declined sharply from Year 1 to Year 2: RBC use fell by 27.9% (9,149 vs. 6,599 units), fresh frozen plasma use fell by 40.3 % (3,615 vs. 2,158), platelets use fell by 22.1 % (1,207 vs. 940), and cryoprecipitate use fell by 37.4% (1,421 vs. 890). These decreases occurred in the face of a 2.9% increase in hospital admissions over 12 months (from 35,348 to 36,421). The decreased transfusion use was accompanied by reduced complications, which declined by 28.6 % (35 transfusion reactions in Year 1 vs. 25 in Year 2). The total cost of blood products declined by $1,027,869 (from $3,694,069 in Year 1 to $2,666,200 in Year 2). The number of type and screen tests requested and performed in the hospital also decreased by 6.3% (from 28,488 in Year 1 to 26,681 in Year 2). Conclusion:We report our one-year experience with a new model for improving transfusion use. Monitoring and intervention in described settings with possibilities of appeal reduced transfusion use by 22–40%. It also appeared to modify physician attitude as exemplified by a 6.3% reduction in type and screen requests in spite of 2.9% increase in admissions. Although small, this decline supports the trend toward fewer transfusions and suggests a change in physician culture and behavior. We recommend other hospitals consider similar versions of this strategy appropriate for their circumstances since it benefits patients and reduces health care costs. Disclosures:No relevant conflicts of interest to declare.

The Role of Thromboelastography in Directing Blood Product Usage in Infant Open Heart Surgery

: Thromboelastography (TEG) measures the dynamics of clot formation in whole blood and provides data that can guide specific blood component therapy. This study analyzed whether the implementation of TEG affected blood product utilization and overall hemostasis in infants (6 months and younger) undergoing open heart surgery. : TEG values measured include R (time to fibrin formation), angle (fibrinogen formation), and MA (platelet function). Blood product usage, TEG values, and operative parameters were collected during surgery on 112 consecutive infants (66 acyanotic) undergoing open heart surgery within the first 6 months of life. Controls consisted of chart data on 70 consecutive patients (57 acyanotic) undergoing the same surgical procedures before implementation of TEG (pre-TEG). : Using TEG, the pattern of blood product utilization changed. Compared with the pre-TEG era, TEG era patients demonstrated a significant increase in fresh frozen plasma usage intraoperatively (4.74 vs. 1.83 mL/kg; P < 0.001) and reduced postoperative use of platelets (1.69 vs. 3.74 mL/kg; P = 0.006) and cryoprecipitate (0.89 vs. 1.95 mL/kg; P = 0.149). Chest tube drainage was significantly reduced at 1, 2, and 24 hours in the TEG group.TEG angle and MA measurements suggest that fibrinogen and platelets of cyanotic patients are more sensitive to hemodilution than the acyanotic patients. : TEG allows for proactive, goal-directed blood component therapy with improved postoperative hemostasis in infants undergoing cardiopulmonary bypass.

Cryoprecipitate: The Current State of Knowledge

Cryoprecipitate is a diverse product containing factor VIII, von Willebrand factor, fibrinogen, fibronectin, factor XIII, and platelet microparticles. The role of this complex product in the management of hemostasis has not been well studied (excluding patients with factor VIII deficiency). There are insufficient data to determine the clinical setting where this product might be clinically efficacious despite its widespread use in multiple different clinical scenarios. The best method of pooling before transfusion has also not been thoroughly investigated to determine the optimal infusion strategy (intralaboratory vs bedside). The most common current indication for the use of this product is hypofibrinogenemia in the setting of massive hemorrhage. There are insufficient data in the literature to determine the efficacy, safety, and dosage in this patient population. Despite 45 years of the use of this product, we still have a lot to learn regarding the optimal use of cryoprecipitate.

Coagulopathy in trauma patients: what are the main influence factors?

Coagulopathy and bleeding after severe injury is a common problem. Whenever caring for critically ill patients, clinicians must anticipate, recognize and manage the coagulopathy of trauma. When left untreated, cardiovascular shock and multiorgan system failure ensue. Uncompensated hemorrhage often culminates in death, highlighting the significance of recognizing the main influences in coagulopathy of trauma. With recent improvements in prehospital care, trauma specialists face more challenging cases than ever before. Hemostatic transfusion strategies, with early and more aggressive use of plasma, platelets, cryoprecipitate and coagulation factor isolates, decrease blood loss in trauma patients. Combined with point-of-care testing for thromboelastography, coagulation panels, lactate and local pO2, there is an opportunity for frontline trauma clinicians to directly improve patient outcomes. Although mortality previously was thought to be summarily independent of medical interventions and resuscitations, we now know the opposite to be true; it is our expectation and indeed our obligation to recognize and manage the coagulopathy of trauma better than in past years. In as much as we continue to prevent acidosis, hypothermia and the progressive coagulopathy following injury, trauma victims the world over are benefiting and surviving longer, living proof that demonstrates the utility of managing the coagulopathy of trauma.