Thrombelastography-Based Monitoring for Massive Blood Loss During Elective Pediatric Surgery for Craniosynostosis Repair, a Pilot Study.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 2110-2110
Author(s):  
Inge M. Appel V ◽  
Andreas Machotta ◽  
Marten Poley ◽  
Maiwenn J Al
Keyword(s):  
Body Weight ◽  
Pilot Study ◽  
Blood Loss ◽  
Pediatric Surgery ◽  
Surgical Repair ◽  
Factor Vii ◽  
Arterial Line ◽  
Blood Products ◽  
Massive Blood Loss ◽  
Dilutional Coagulopathy

Abstract Abstract 2110 Poster Board II-87 The management of massive blood loss in children during trauma or major surgery is still an unsolved problem in pediatric surgery and anesthesia. Primary operative repair of craniosynostosis in infants and young children can serve as a model for excessive acute blood loss. The introduction of thromboelastography (TEG) has led to a significant decrease in transfusion of packed red blood cells (pRBC), fresh frozen plasma (FFP) and platelets in adult surgery, thereby diminishing the risks of infections and immunosuppression. Moreover a significant decrease in accompanying costs has been reported. However, no studies have evaluated the effect of TEG-guided treatment on the amount of transfused blood products in children. The primary objective of this pilot study is to obtain reference TEG-values in children during surgical repair of primary craniosynostosis. We performed a single-center pilot study on TEG-monitoring in children during craniofacial surgery. Methods: The study includes 21 children with craniosynostosis undergoing elective craniofacial repair at the Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands. Blood samples (5 ml blood taken from an arterial line) for TEG (Haemoscope®) measurement were obtained after induction of anesthesia (T1), after the application of Ringer's lactated solution (RLS) 10 ml × kg-1 body weight (T2), after the application of hetastarch 130/0.4 6% (Venofundin®, Fresenius Kabi) (T3), after transfusion of pRBC (T4), and eventually after the application of FFP (T5). Results: 21 children, less than 20 months of age, with a mean body weight of 8.5 kg underwent surgical repair of craniosynostosis. They were treated according to the local protocol on massive blood loss in children during surgery. Nine children were suffering from scaphocephalie, 4 from trigonocephalie, 3 from plagiocephalie, one from brachycephalie and 4 children had a mixed or complex form of craniosynostosis such as Crouzon disease. After the induction of anaesthesia (T1) and after the administration of RLS (T2) no changes in clot strength were seen, MA remained mean 62 mm. However, between T2 and T3 all children demonstrated a significant decline in hemoglobine from mean 6.5 to 3.8 mmol/L (p<.0005). The blood loss was mean 380 ml at T3, ranging from 200 to 700 ml, requiring mean 190 ml transfusion of pRBC (range 100-390 ml). The TEG values at T3 showed a concurrent decrease of alpha (from 66° to 57°) and MA (from 62 to 48mm) with an increasing k (from 1.7 to 3.0 min) in kaolin activated TEG measurements. Together with a decrease in MA in TEG–FF at T3 (from 18 to 5.5 mm) this demonstrates a dilutional coagulopathy. All changes were highly significant with p<.0005. Transfusion of pRBC at T4 did not change TEG parameters. No signs of fibrinolysis were seen. Discussion: The administration of hetastarch 130/0.4 6% at T3 resulted in a dilutional coagulopathy. This is due to blood loss, consumption of coagulation factors and platelets, and intravascular volume replacement. During blood loss fibrinogen synthesis will be limited. Additionally, the decreasing functional fibrinogen levels (MA-FF) point to reduced strength of the clot. Administering cryoprecipitate or concentrates of fibrinogen in an early phase might maintain clot firmness and thereby decrease blood loss and reduce the number of transfused blood products. Conclusion: In an attempt to decrease the amount of transfused blood products TEG will allow tailored interventions during pediatric surgery with specific medications like antifibrinolytic agents, concentrates of fibrinogen, or activated recombinant factor VII. Finally, TEG tailored therapy may decrease blood transfusions and transfusion related complications in children. These data strongly support the evaluation of TEG-guided interventions in children during massive blood loss. Disclosures: No relevant conflicts of interest to declare.

A Jehovah's Witness with Complex Abdominal Trauma and Coagulopathy: Use of Factor VII and a Review of the Literature

2005 ◽  
Vol 71 (5) ◽  
pp. 414-415 ◽  
Author(s):  
James Haan ◽  
Thomas Scalea
Keyword(s):  
Blood Loss ◽  
Factor Viia ◽  
Factor Vii ◽  
Jehovah’S Witnesses ◽  
Acute Bleeding ◽  
Jehovah's Witnesses ◽  
Life Saving ◽  
Surgical Bleeding ◽  
Dilutional Coagulopathy ◽  
Real Challenge

Management of acute bleeding in patients who are Jehovah's Witnesses remains a challenge. Clearly, the most important concept is meticulous and early hemostasis to minimize ongoing blood loss. This is generally followed by supportive measures. Dilutional coagulopathy can present a real challenge, as therapeutic options are quite limited in this group of patients. We present a patient who arrived in hemorrhagic shock, and despite early surgical therapy, his significant blood loss caused dilutional coagulopathy that we treated with activated factor VIIa. While use of factor VIIa after injury is gaining popularity, data on its use in patients who are Jehovah's Witnesses is quite limited. In this case, we believe the product was life-saving. Most importantly, there were no religious objections to its use. In appropriate patients, when surgical bleeding is controlled and there is still evidence of dilutional coagulopathy, factor VIIa may have a real role in patients, particularly those who are Jehovah's Witnesses.

The effect of aprotinin, tranexamic acid, and aminocaproic acid on blood loss and use of blood products in major pediatric surgery: A meta-analysis

2009 ◽  
Vol 10 (2) ◽  
pp. 182-190 ◽  
Author(s):  
Esther S. Schouten ◽  
Alma C. van de Pol ◽  
Anton N. J. Schouten ◽  
Nigel M. Turner ◽  
Nicolaas J. G. Jansen ◽  
...  
Keyword(s):  
Blood Loss ◽  
Tranexamic Acid ◽  
Pediatric Surgery ◽  
Meta Analysis ◽  
Aminocaproic Acid ◽  
Blood Products

Use of Activated Recombinant Factor VII for the Control of Post Partum Hemorrhage (PPH).

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 4027-4027
Author(s):  
Nazli H. Hossain ◽  
Tasneem F. Farzana ◽  
Tahir S. Shamsi ◽  
Nargis S. Soomro
Keyword(s):  
Blood Loss ◽  
Post Partum ◽  
Multiorgan Failure ◽  
Factor Vii ◽  
Blood Products ◽  
Safety Issues ◽  
Vacuum Delivery ◽  
Internal Iliac ◽  
The Mean ◽  
Mean Time

Abstract Objective: To evaluate the efficacy and safety of activated recombinant factor VII (rFVIIa) in the control of PPH Patients and Methods: All patients with massive PPH who failed medical and surgical treatment were eligible for the investigation. Massive PPH was defined as loss of > 1000 ml of blood within 24 h after delivery. Patients were considered for treatment with rFVIIa after failure of conventional measures such administration of myotonic agents including oxytocin, ergotamine, misoprostol and failure of other interventions aimed at controlling blood loss such as ligation of uterine and ovarian vessels, or ligation of internal iliac artery. The primary outcome measures were control of the bleeding episode and reduction in the number of administered blood products. Results: A total of 16 patients with massive PPH were eligible for the current study. Vaginal and vacuum delivery was used in 6 patients while 10 patients underwent C-section. The mean dose of rFVIIa was 68 mcg/kg administered intravenously as a single bolus injection. Mean time of diagnosing PPH and administration was 5.5 hours (+/−2). The mean number of blood products used prior the administration of rFVIIa was 14 units RBC and 12 units of FFP. Cessation of blood loss was achieved in 14 patients within an average of 20 minutes after the administration of rFVIIa. The blood products utlilized after the administration of rFVIIa in these patients were 2 URBC and 2UFFP. The uterus was conserved in 7 patients who received rFVIIa prior to hysterectomy. While in 9 patients rFVIIa was administered after failure of hysterectomy to control blood loss. Of the 16 patients, 3 died because of multiorgan failure following severe blood loss. No adverse events including thromboembolic phenomena were observed. Conclusion: Massive PPH is the most common cause of maternal mortality in developing countries. The use of rFVIIa in patients with massive PPH can achieve hemostasis with a single dose only. The administration of rFVIIa in patients with massive PPH may avoid the need for hysterectomy. There were no safety issues in the current study. Further trials should address the dose and timing of administration of rFVIIa in patients with massive PPH.

DIFFERENTIATED PRESCRIPTION OF HEMOSTATIC DRUGS AT ACUTE MASSIVE BLOOD LOSS

2017 ◽  
Author(s):  
М. Глотов ◽  
А. Биркун ◽  
Е. Рябикина ◽  
С. Самарин ◽  
М. Федосов
Keyword(s):  
Blood Loss ◽  
Central Place ◽  
Fresh Frozen Plasma ◽  
Multiple Organ ◽  
Basic Drugs ◽  
Clotting Factors ◽  
Massive Blood Loss ◽  
Fresh Frozen ◽  
Dilutional Coagulopathy ◽  
Frozen Plasma

Острая массивная кровопотеря (ОМК) остается тяжелым осложнением с высокой летальностью. Центральное место в танатогенезе этого состояния занимают нарушения коагуляции. ДВС-синдром и дилюционная коагулопатия часто осложняют ОМК и приводят к развитию полиорганной недостаточности. В статье рассмотрены современные подходы к назначению гемостатических средств при ОМК, принятые на территории РФ. Базисными препаратами для лечения ОМК являются свежезамороженная плазма, тромбоцитный концентрат, криопреципитат, отдельные факторы свертывания крови, препараты кальция и транексамовая кислота. Правильное использование этих средств предполагает адекватный мониторинг коагуляции. Acute massive blood loss (AMBL) remains to be a severe complication with high mortality rate. Coagulation disorders take central place in tanatogenesis of this condition. DIC-syndrome and dilutional coagulopathy are often complicated by AMBL and lead to development of multiple organ failure. This article presents current approaches that are accepted in Russian Federation of hemostatic drugs prescription in AMBL treatment. Fresh frozen plasma, platelet concentrate, cryoprecipitate, some clotting factors, calcium and tranexamic acid are basic drugs for AMBL treatment. Adequate coagulation monitoring is required for correct use of these drugs.

The Effect of Dextran of Various Molecular Weight on the Coagulation in Dogs

1961 ◽  
Vol 06 (01) ◽  
pp. 015-024 ◽  
Author(s):  
Sven Erik Bergentz ◽  
Oddvar Eiken ◽  
Inga Marie Nilsson
Keyword(s):  
Molecular Weight ◽  
Body Weight ◽  
High Molecular Weight ◽  
Bleeding Time ◽  
Factor Vii ◽  
Low Molecular Weight ◽  
Factor V ◽  
Coagulation Mechanism ◽  
Coagulation Defects

Summary1. Infusions of low molecular weight dextran (Mw = 42 000) to dogs in doses of 1—1.5 g per kg body weight did not produce any significant changes in the coagulation mechanism.2. Infusions of high molecular weight dextran (Mw = 1 000 000) to dogs in doses of 1—1.5 g per kg body weight produced severe defects in the coagulation mechanism, namely prolongation of bleeding time and coagulation time, thrombocytopenia, pathological prothrombin consumption, decrease of fibrinogen, prothrombin and factor VII, factor V and AHG.3. Heparin treatment of the dogs was found to prevent the decrease of fibrinogen, prothrombin and factor VII, and factor V otherwise occurring after injection of high molecular weight dextran. Thrombocytopenia was not prevented.4. In in vitro experiments an interaction between fibrinogen and dextran of high and low molecular weight was found to take place in systems comprising pure fibrinogen. No such interaction occurred in the presence of plasma.5. It is concluded that the coagulation defects induced by infusions of high molecular weight dextran are due to intravascular coagulation.

Hand-assisted laparoscopic nephrectomy in morbidly obese patients

2020 ◽  
Vol 99 (6) ◽  
pp. 271-276
Keyword(s):  
Body Weight ◽  
Surgical Technique ◽  
Blood Loss ◽  
Hospital Stay ◽  
Kidney Cancer ◽  
The Body ◽  
Laparoscopic Nephrectomy ◽  
Morbidly Obese ◽  
Obese Patients ◽  
Morbid Obese

Introduction: Prevalence of obesity is 30 % in the Czech Republic and is expected to increase further in the future. This disease complicates surgical procedures but also the postoperative period. The aim of our paper is to present the surgical technique called hand-assisted laparoscopic nephrectomy (HALS), used in surgical management of kidney cancer in morbid obese patients with BMI >40 kg/m2. Methods: The basic cohort of seven patients with BMI >40 undergoing HALS nephrectomy was retrospectively evaluated. Demographic data were analyzed (age, gender, body weight, height, BMI and comorbidities). The perioperative course (surgery time, blood loss, ICU time, hospital stay and early complications), tumor characteristics (histology, TNM classification, tumor size, removed kidney size) and postoperative follow-up were evaluated. Results: The patient age was 38−67 years; the cohort included 2 females and 5 males, the body weight was 117−155 kg and the BMI was 40.3−501 kg/m2. Surgery time was 73−98 minutes, blood loss was 20−450 ml, and hospital stay was 5−7 days; incisional hernia occurred in one patient. Kidney cancer was confirmed in all cases, 48–110 mm in diameter, and the largest removed specimen size was 210×140×130 mm. One patient died just 9 months after the surgery because of metastatic disease; the tumor-free period in the other patients currently varies between 1 and 5 years. Conclusion: HALS nephrectomy seems to be a suitable and safe surgical technique in complicated patients like these morbid obese patients. HALS nephrectomy provides acceptable surgical and oncological results.

scholarly journals Outcome of Major Hemorrhage at a Major Cardiothoracic Center in Patients with Activated Major Hemorrhage Protocol versus Nonactivated Protocol

2021 ◽  
Vol 47 (01) ◽  
pp. 074-083
Author(s):  
Kathryn W. Chang ◽  
Steve Owen ◽  
Michaela Gaspar ◽  
Mike Laffan ◽  
Deepa R. J. Arachchillage
Keyword(s):  
Fresh Frozen Plasma ◽  
Electronic Records ◽  
Blood Products ◽  
Major Hemorrhage ◽  
Fresh Frozen ◽  
Dilutional Coagulopathy ◽  
Baseline Characteristics ◽  
The Impact ◽  
Frozen Plasma ◽  
Baseline Hemoglobin

AbstractThis study aimed to determine the impact of major hemorrhage (MH) protocol (MHP) activation on blood administration and patient outcome at a UK major cardiothoracic center. MH was defined in patients (> 16 years) as those who received > 5 units of red blood cells (RBCs) in < 4 hours, or > 10 units in 24 hours. Data were collected retrospectively from patient electronic records and hospital transfusion databases recording issue of blood products from January 2016 to December 2018. Of 134 patients with MH, 24 had activated MHP and 110 did not have activated MHP. Groups were similar for age, sex, baseline hemoglobin, platelet count, coagulation screen, and renal function with no difference in the baseline clinical characteristics. The total number of red cell units (median and [IQR]) transfused was no different in the patients with activated (7.5 [5–11.75]) versus nonactivated (9 [6–12]) MHP (p = 0.35). Patients in the nonactivated MHP group received significantly higher number of platelet units (median: 3 vs. 2, p = 0.014), plasma (median: 4.5 vs. 1.5, p = 0.0007), and cryoprecipitate (median: 2 vs. 1, p = 0.008). However, activation of MHP was associated with higher mortality at 24 hours compared with patients with nonactivation of MHP (33.3 vs. 10.9%, p = 0.005) and 30 days (58.3 vs. 30.9%, p = 0.01). The total RBC and platelet (but not fresh frozen plasma [FFP]) units received were higher in deceased patients than in survivors. Increased mortality was associated with a higher RBC:FFP ratio. Only 26% of patients received tranexamic acid and these patients had higher mortality at 30 days but not at 24 hours. Deceased patients at 30 days had higher levels of fibrinogen than those who survived (median: 2.4 vs. 1.8, p = 0.01). Patients with activated MHP had significantly higher mortality at both 24 hours and 30 days despite lack of difference in the baseline characteristics of the patients with activated MHP versus nonactivated MHP groups. The increased mortality associated with a higher RBC:FFP ratio suggests dilutional coagulopathy may contribute to mortality, but higher fibrinogen at baseline was not protective.

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