scholarly journals Whole blood transfusion versus component therapy in adult trauma patients with acute major haemorrhage

2020 ◽  
Vol 37 (6) ◽  
pp. 370-378 ◽  
Author(s):  
Pascale Avery ◽  
Sarah Morton ◽  
Harriet Tucker ◽  
Laura Green ◽  
Anne Weaver ◽  
...  
Keyword(s):  
Whole Blood ◽  
Statistical Difference ◽  
Damage Control ◽  
Controlled Trial ◽  
Primary Objective ◽  
Major Haemorrhage ◽  
Blood Component ◽  
Trauma Patients ◽  
Transfusion Strategy ◽  
Significant Difference

ObjectiveIn the era of damage control resuscitation of trauma patients with acute major haemorrhage, transfusion practice has evolved to blood component (component therapy) administered in a ratio that closely approximates whole blood (WB). However, there is a paucity of evidence supporting the optimal transfusion strategy in these patients. The primary objective was therefore to establish if there is an improvement in survival at 30 days with the use of WB transfusion compared with blood component therapy in adult trauma patients with acute major haemorrhage.MethodologyA systematic literature search was performed on 15 December 2019 to identify studies comparing WB transfusion with component therapy in adult trauma patients and mortality at 30 days. Studies which did not report mortality were excluded. Methodological quality of included studies was interpreted using the Cochrane risk of bias tool, and rated using the Grading of Recommendations Assessment, Development and Evaluation approach.ResultsSearch of the databases identified 1885 records, and six studies met the inclusion criteria involving 3255 patients. Of the three studies reporting 30-day mortality (one randomised controlled trial (moderate evidence) and two retrospective (low and very low evidence, respectively)), only one study demonstrated a statistically significant difference between WB and component therapy, and two found no statistical difference. Two retrospective studies reporting in-hospital mortality found no statistical difference in unadjusted mortality, but both reported statistically significant logistic regression analyses demonstrating that those with a WB transfusion strategy were less likely to die.ConclusionRecognising the limitations of this systematic review relating to the poor-quality evidence and limited number of included trials, it does not provide evidence to support or reject use of WB transfusion compared with component therapy for adult trauma patients with acute major haemorrhage.PROSPERO registration numberCRD42019131406.

Anastomotic Outcomes in Military Exploratory Laparotomies in the Modern Combat Era

2022 ◽  
pp. 000313482110502
Author(s):  
Patrick F. Walker ◽  
Joseph D. Bozzay ◽  
David W. Schechtman ◽  
Faraz Shaikh ◽  
Laveta Stewart ◽  
...  
Keyword(s):  
Medical Center ◽  
Damage Control ◽  
Surgical Site Infections ◽  
Trauma Patients ◽  
Intestinal Anastomoses ◽  
Military Hospitals ◽  
Anastomotic Failure ◽  
Significant Difference ◽  
Regional Medical Center ◽  
Outcome Differences

Background Intestinal anastomoses in military settings are performed in severely injured patients who often undergo damage control laparotomy in austere environments. We describe anastomotic outcomes of patients from recent wars. Methods Military personnel with combat-related intra-abdominal injuries (June 2009-December 2014) requiring laparotomy with resection and anastomosis were analyzed. Patients were evacuated from Iraq or Afghanistan to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals. Results Among 341 patients who underwent 1053 laparotomies, 87 (25.5%) required ≥1 anastomosis. Stapled anastomosis only was performed in 57.5% of patients, while hand-sewn only was performed in 14.9%, and 9.2% had both stapled and hand-sewn techniques (type unknown for 18.4%). Anastomotic failure occurred in 15% of patients. Those with anastomotic failure required more anastomoses (median 2 anastomoses, interquartile range [IQR] 1-3 vs. 1 anastomosis, IQR 1-2, P = .03) and more total laparotomies (median 5 laparotomies, IQR 3-12 vs. 3, IQR 2-4, P = .01). There were no leaks in patients that had only hand-sewn anastomoses, though a significant difference was not seen with those who had stapled anastomoses. While there was an increasing trend regarding surgical site infections (SSIs) with anastomotic failure after excluding superficial SSIs, it was not significant. There was no difference in mortality. Discussion Military trauma patients have a similar anastomotic failure rate to civilian trauma patients. Patients with anastomotic failure were more likely to have had more anastomoses and more total laparotomies. No definitive conclusions can be drawn about anastomotic outcome differences between hand-sewn and stapled techniques.

The Effects of Thrombocytopenia on Clotting Profile in Whole Blood As Determined By Thromboelastography When Anticoagulant Is Present at Therapeutic or Prophylactic Concentration

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 1550-1550
Author(s):  
Jason Chung ◽  
Ivan Stevic ◽  
Jorell Gantioque ◽  
Anthony K.C. Chan ◽  
Howard H.W. Chan
Keyword(s):  
Anticoagulant Therapy ◽  
Whole Blood ◽  
Statistical Difference ◽  
Conflicts Of Interest ◽  
Maximum Amplitude ◽  
Clot Formation ◽  
Bleeding Tendency ◽  
Therapeutic Concentration ◽  
Significant Difference

Abstract Background: Anticoagulant therapy for the treatment of venous thromboembolism in patients with concomitant thrombocytopenia has been based on anecdotal evidence. The platelet (PLT) threshold at which anticoagulant therapy should be withheld is still controversial. A PLT count of 50 × 109/L was recommended to be the threshold in the past, but newer reviews have lowered the threshold to 30 × 109/L. We previously used thromboelastography (TEG) to study clotting in plasma reconstituted with autologous PLT. Since red cells also play a significant role in hemostasis and coagulation, we hereby developed a TEG model with whole blood (WB) in order to better mimic in vivo conditions to evaluate the clot formation in thrombocytopenic blood. Objective: Using TEG to monitor clotting in whole blood samples containing unfractionated heparin (UFH) or dalteparin, we evaluated the differences in clotting profile when PLT in the samples were reduced to thrombocytopenic range. Methods: Whole blood was collected from healthy volunteers in syringes containing citrate phosphate dextrose adenine (CDPA-1, pH=5.5) and 30 μg/L corn trypsin inhibitor. Magnetic CD 61 antibody chromatography was used to deplete PLT in the blood to a count of ≤ 15 × 109/L. Platelet-depleted whole blood (PDWB) was then mixed with untouched blood from the same donor to obtain the predefined PLT counts. Clotting was initiated in the TEG cups with 10 mM CaCl2 and tissue factor (TF) in the presence of either UFH (0.3 U/mL or 0.1 U/mL) or dalteparin (1 IU/mL or 0.3 IU/mL). Due to the mechanistic differences between UFH and dalteparin, we optimized the amount of TF to maximize the sensitivity of TEG assay for individual anticoagulants; thus, 2.25 pM and 2.05 pM were used for UFH and dalteparin experiments, respectively. However, the same amount of TF was used to evaluate the clotting with the same anticoagulant at both therapeutic and prophylactic concentrations. Clotting was monitored using a Haemoscope TEG at 37 ºC for a maximum of 3 hr or until maximum amplitude (MA) had been achieved. Three parameters of clotting profile including R, MA and area under the curve within the first 15 min of clotting (AUC15) were used for further analysis. A p-value < 0.05 was considered statistically significant. Results: All3 parameters showed significant compromise of clotting when PLT decreased from 150 × 109/L to < 15 × 109/L in the presence of UFH or dalteparin at therapeutic range. When these anticoagulants were reduced to prophylactic concentration, the clotting was also significantly moderated, but to a lesser extent, comparing samples with PLT at 150 × 109/L and those with PLT < 15 × 109/L. These are in accordance with the bleeding tendency in vivo. At 30 × 109/L, the newer recommended PLT threshold at which anticoagulant should be withheld in thrombocytopenic patients, the clotting parameters did not show any significant difference as compared to those at the traditional threshold of 50 × 109/L when UFH and dalteparin were at therapeutic concentrations. Similarly, when UFH was reduced to a prophylactic concentration, we detected no significant difference in the clotting profile between 50 × 109 PLT/L and 30 × 109 PLT/L. In contrast, in samples with dalteparin at a prophylactic concentration, MA was significantly lower at 30 × 109 PLT/L when compared with that at 50 × 109 PLT/L although R and AUC15 had no statistical difference. Additionally, samples of PDWB containing either anticoagulant at prophylactic concentration had better clot formation than those samples of 50 × 109 PLT/L containing UFH or dalteparin at therapeutic concentration. Conclusion: The TEG profile of WB clotting in this in vitro model simulates bleeding tendency observed clinically. In the presence of UFH or dalteparin at therapeutic concentration, there was no statistical difference in the TEG parameters comparing thrombocytopenic blood with 50 × 109 PLT/L and 30 × 109 PLT/L, supporting the latter as the new threshold to hold anticoagulant in thrombocytopenic patients. In addition, instead of holding all anticoagulants in severe thrombocytopenic patients with PLT < 30 × 109/L, administering UFH or dalteparin at prophylactic doses may offer a safe alternative, as both imped clotting in TEG even less than those at therapeutic concentration with thrombocytopenic blood at 50 × 109 PLT/L. Fig 1. TEG profile of clots with UFH Fig 1. TEG profile of clots with UFH Fig 2. TEG profile of clots with dalteparin Fig 2. TEG profile of clots with dalteparin Disclosures No relevant conflicts of interest to declare.

Dexamethasone (DM) for cancer-related fatigue: A double-blinded, randomized, placebo-controlled trial.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 9002-9002 ◽  
Author(s):  
Sriram Yennurajalingam ◽  
Susan Frisbee-Hume ◽  
Marvin Omar Delgado-Guay ◽  
Janet Bull ◽  
Alexandria T. Phan ◽  
...  
Keyword(s):  
Advanced Cancer ◽  
Controlled Trial ◽  
Symptom Assessment ◽  
Primary Objective ◽  
Controlled Study ◽  
Advanced Cancer Patients ◽  
Double Blind ◽  
Cancer Related Fatigue ◽  
Significant Difference ◽  
Edmonton Symptom Assessment Scale

9002 Background: Cancer-related-fatigue (CRF) is the most common and distressing symptoms in patients with advanced cancer. Currently, there is no standard treatment for CRF. Although corticosteroids have been used in the treatment of CRF, there are no well-powered placebo-controlled trials that used a validated CRF outcome measure. The primary objective of this prospective, randomized, double-blind, placebo-controlled study is to compare the effect of DM versus placebo on CRF. Methods: Advanced cancer patients with fatigue ≥ 4/10 on the Edmonton Symptom Assessment Scale (ESAS) and at least 2 other CRF-related symptoms (pain, nausea, appetite, depression, anxiety or sleep disturbance ≥ 4/10), normal cognition, no infections and hemoglobin ≥ 9 g/L were eligible for enrollment. Patients were randomized to either receive dexamethasone 4 mg orally twice a day for 15 days (primary end point) or matching placebo. The primary outcome was the day 15 change in Functional Assessment of Chronic Illness-Fatigue (FACIT-F) subscale scores. Differences in the group means (normal distribution) were analyzed using the two-sample t-test. Results: In 83 evaluable patients (43 DM and 40 placebo), median age was 60 years, 61% were white, and 53% were female. There was no difference in the demographics and fatigue (FACIT-F subscale) between DM and placebo groups except for sex (p=0.02). The mean (SD) FACIT-F subscores at baseline and at day 15 for DM were 18 (11) and 27 (11) (p<0.001) and for placebo were 21 (9) and 24 (12) (p=0.06), respectively. Mean improvement in FACIT-F subscale was significantly higher in the DM group compared to placebo (9.6 (11) vs. 3.1 (9.7), p=0.005). We found a significant difference in ESAS physical distress (p=0.02), but no differences in ESAS overall symptom distress (p=0.11) and ESAS psychological distress (P=0.88) between DM and placebo. There were insignificantly higher numbers of grade ≥3 toxicities in patients who received DM than in patients who received placebo (20/42 vs. 18/47, p=0.37). Conclusions: Dexamethasone was more effective than placebo in reducing CRF in patients with advanced cancer. Long-term safety studies are needed.

Inhibiting effect of etomidate or propofol combined with remifentanil hydrochloride on adrenal cortex function in severe burn patients : a randomized, double-blind and controlled trial

2020 ◽  
Author(s):  
xiulan Liu ◽  
guoyu Ji ◽  
haibo Liu ◽  
jingmin Zhang ◽  
ruhong Li ◽  
...  
Keyword(s):  
Adrenal Cortex ◽  
Statistical Difference ◽  
Controlled Trial ◽  
Statistical Significance ◽  
Patient Characteristics ◽  
Anesthesia Induction ◽  
Severe Burn ◽  
Significant Difference ◽  
Significant Change ◽  
Time Point

Abstract Background: Etomidate is widely used for anesthetic induction in clinical practice. Adrenal insufficiency induced by etomidate has been demonstrated. However, a variety of studies present that etomidate plays an important role in patients with severe burn injuries.Methods: Forty patients with severe burns were randomly divided into etomidate group (Group E) and propofol group (Group P). Etomidate, propofol and remifentanil hydrochloride were used for anesthesia induction and maintenance. General patient characteristics, mean arterial pressure (MAP), heart rate (HR) and bispectral index (BIS) value were measured and recorded at the baseline (t0), before the intubation (t1), 1, 3, 5, and 30 min following the intubation (t2–5), and the end of the surgery (t6). Before induction of anesthesia and at 30 min, 2h, 24h, and 48h after end of surgery (T0, T1, T2, T3 and T4), artery blood (2 ml) was collected and the concentrations of adrenocorticotropic hormone (ACTH), cortisol (Cor) and aldosterone (ALD) were measured.Results: There were no significant difference in general patient characteristics between the two groups (P>0.05). The MAP values decreased significantly, the HR values decreased at the t1 and there was a statistical difference between the two groups; There was no statistical difference between the two groups at each time point. The patient's ACTH levels in two groups decreased significantly compared with that at preanesthesia, and the levels at T4 were apparently higher than T3 in Group E. The patient's Cor levels in Group E significantly decreased at T2, while that in Group P have no significant change. The differences were not statistical significance between the two groups. The patient's ALD levels in Group E were significantly lower than before induction; while the levels in Group P have no significant change at each time point; the levels in Group P were apparently higher than group E at T2, T3 and T4.Conclusion: Propofol and etomidate for anesthesia induction and maintenance could cause hemodynamic changes, but the effect of etomidate was lighter. The propofol and etomidate both suppress adrenal cortex function, that inhibitory effect of etomidate was greater than propofol, therefore etomidate had a certain beneficial effect.

scholarly journals Bupivacaine Lozenge Compared with Lidocaine Spray as Topical Pharyngeal Anesthetic before Unsedated Upper Gastrointestinal Endoscopy: A Randomized, Controlled Trial

2014 ◽  
Vol 7 ◽  
pp. CGast.S18019 ◽  
Author(s):  
Nesrin Salale ◽  
Charlotte Treldal ◽  
Stine Mogensen ◽  
Mette Rasmussen ◽  
Janne Petersen ◽  
...  
Keyword(s):  
Gastrointestinal Endoscopy ◽  
Controlled Trial ◽  
Primary Objective ◽  
Upper Gastrointestinal Endoscopy ◽  
Patient Discomfort ◽  
Significant Difference ◽  
Group A ◽  
Gag Reflex ◽  
Lidocaine Spray ◽  
Upper Gastrointestinal

Unsedated upper gastrointestinal endoscopy (UGE) can induce patient discomfort, mainly due to a strong gag reflex. The aim was to assess the effect of a bupivacaine lozenge as topical pharyngeal anesthetic compared with standard treatment with a lidocaine spray before UGE. Ninety-nine adult outpatients undergoing unsedated diagnostic UGE were randomized to receive either a bupivacaine lozenge (L-group, n = 51) or lidocaine spray (S-group, n = 42). Primary objective was assessment of patient discomfort including acceptance of the gag reflex during UGE. The L-group assessed the discomfort significantly lower on a visual analog scale compared with the S-group ( P = 0.02). There was also a significant difference in the four-point scale assessment of the gag reflex ( P = 0.03). It was evaluated as acceptable by 49% in the L-group compared with 31% in the S-group. A bupivacaine lozenge compared with a lidocaine spray proved to be a superior option as topical pharyngeal anesthetic before an UGE.

Quality of life in RCT of pasireotide to reduce pancreatic complications following resection.

2015 ◽  
Vol 33 (3_suppl) ◽  
pp. 393-393
Author(s):  
Anne Eaton ◽  
Mithat Gonen ◽  
Paul Jack Karanicolas ◽  
Michael Ian D'Angelica ◽  
Ronald P. DeMatteo ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Controlled Trial ◽  
Unmet Need ◽  
Secondary Analysis ◽  
Primary Objective ◽  
Recent Trial ◽  
Double Blind ◽  
Significant Difference ◽  
Eortc Qlq

393 Background: A recent trial demonstrated that prophylactic pasireotide reduces pancreatic complication (PC) rates (primary objective). In this secondary analysis, we describe quality of life (QoL) in this population before and after resection using a standard instrument (the EORTC QLQ-C30) and the EORTC pancreatic cancer module (PAN26), which was recently developed to address the unmet need for QoL assessment in this subpopulation. Also of interest is assessing the association between PC and QoL and testing the hypothesis that pasireotide improves QoL. Methods: We conducted a randomized, double-blind, placebo-controlled trial of preoperative subcutaneous pasireotide in 300 patients undergoing pancreaticoduodenectomy or distal pancreatectomy. Participants completed the C30 and PAN26 preoperatively and on postoperative days 14 and 60. Scores were compared using paired t-tests. Results: All patients completed at least one questionnaire and 87% of patients completed all three. No major differences in QoL were seen between treatment groups so pooled results were reported. A significant worsening of function at 14 days was detected on all PAN26 and C30 function scales except hepatic and emotional functioning (EF), and all C30 symptom scales (all p<.01). These effects lessened by 60 days, but scores remained significantly worse than baseline with the exception of the sexuality, cognitive functioning, nausea and vomiting, insomnia and constipation scales, which returned to near baseline, and EF, which was significantly better than baseline (p=0.03). PC occurred in 45 patients and was associated with worse body image, dyspnea, financial difficulties and physical, role, emotional and social functioning at 14 and 60 days (all p<.05). Conclusions: During the first 14 days following resection, patients can be expected to have a significant decline in QoL. Many symptoms abate by 60 days, and EF improves. Although pasireotide effectively reduced PC, its effect did not appear to translate to improved QoL based on this sample of 300 patients. While PC was associated with worse QoL, most patients in both pasireotide and placebo groups did not experience PC, which may explain why no significant difference in QoL was observed. Clinical trial information: NCT00994110.

scholarly journals Transfusion Strategies in the Pre-Hospital Setting: Evaluating the Logistical Benefits of Pre-Hospital Whole Blood Transfusion, and a National Survey of Pre-Hospital Blood Transfusion

2021 ◽  
Author(s):  
Harriet Tucker ◽  
Laura Green ◽  
Karim Brohi ◽  
Rebecca Cardigan ◽  
Ross Davenport ◽  
...  
Keyword(s):  
Blood Transfusion ◽  
National Survey ◽  
Whole Blood ◽  
Hospital Setting ◽  
Flow Time ◽  
Transfusion Practice ◽  
Blood Component ◽  
Trauma Patients ◽  
Time Analysis ◽  
Blood Component Transfusion

Abstract BackgroundPre-hospital blood component transfusion poses logistical challenges. Current patterns of pre-hospital blood use across the UK are not known. A potential benefit of providing a single combined component of whole blood is reduced need for multiple steps of administering separate components and more efficient use of time and resources by medical staff. .Objectivesto undertake a detailed time-analysis of the steps of pre-hospital combined component transfusion against separate blood component transfusion, and to determine current UK pre-hospital transfusion practice and users’ optimal pre-hospital transfusion strategyMethodsA three-arm cross-over major haemorrhage simulation study compared: flow-time (time from decision-to-transfuse [DTT] to complete transfusion); touch-time (direct team ’hands on’ contact time with transfusion process); and number of steps, people and equipment required for transfusion of 2 units of RCP [arm-A], 2 RBC + 2 TP [arm-B] or RBC + 2 Lyoplas [arm-C]). A national survey of current and optimal pre-hospital transfusion strategies was sent to 22 UK Air Ambulance Services (AAS) and 27 Major Trauma Centres (MTC) in December 2019. ResultsThe simulation demonstrated that arm-A had a shorter flow-time (median 6min 31sec vs. 12min 20 sec, vs 16min 29 sec) and touch-time (median 2min 31 seconds vs. 5min 21sec vs. 15min 3sec) than arm-B and arm-C respectively, and required fewer steps, equipment and checks. 18 MTCs and 18 AAS responded to the national survey (response rates of 67 and 82%). 10 transfused RBC/plasma (5 TP/5 Lyoplas), 4 RBC only, 2 Lyoplas only, 1 RBC/Lyoplas/Fibrinogen, and 1 ’red cell and plasma’ (only available at one hospital site). 89% replied that a combined component transfusion would be desirable, as it would reduce patient mortality (83%) and tasks on scene (75%). ConclusionThe time-analysis established the benefits for combined pre-hospital component transfusion in trauma patients. The national survey demonstrates the variation in current pre-hospital transfusion practice and reiterates that combined component transfusion pre-hospital may have logistical advantages over separate components.

Sign in / Sign up

Export Citation Format

Share Document