scholarly journals Management of Major Obstetric Haemorrhage using ROTEM Point-of-Care Haemostasis Analysers Can Reduce Blood Product usage Without Increasing Fibrinogen Replacement Therapy

2018 ◽  
Vol 11 (3) ◽  
pp. 1167-1176
Author(s):  
Beatrice O. Ondondo
Keyword(s):  
Blood Loss ◽  
Replacement Therapy ◽  
Blood Product ◽  
Point Of Care ◽  
Blood Products ◽  
Transfusion Therapy ◽  
Product Usage ◽  
Obstetric Haemorrhage ◽  
Coagulation Tests ◽  
Fibrinogen Replacement Therapy

Major obstetric haemorrhage (MOH) is a leading cause of maternal death and morbidity, with the majority of deaths occurring within four hours of delivery. Therefore, prompt identification of women at risk of MOH is crucial for the rapid assessment and management of blood loss to urgently restore haemodynamic stability. Furthermore, as the rate of blood loss during MOH can increase rapidly in the time when laboratory results are awaited, the management of MOH could benefit from point-of-care coagulation testing by the ROTEM analyser which has a quicker turnaround time compared to standard laboratory coagulation tests. A number of studies indicate that ROTEM-based management of MOH has resulted in a significant reduction in massive transfusions and decreased transfusion of concentrated red cells (CRC) and fresh frozen plasma (FFP) due to a reduction in total blood loss. Several reports which have linked MOH to the depletion of fibrinogen reserves indicate that the reduction in CRC and FFP transfusions is largely due to an increase in early fibrinogen replacement therapy which corrects hypofibrinogenemia. This short report discusses preliminary findings on the impact of ROTEM point-of-care haemostasis analyser on the transfusion of various blood products to obstetric women experiencing MOH at the Royal Gwent Hospital in South wales. The number of blood products transfused following decisions based on the ROTEM analyser measurements (ROTEM group) was compared to historical transfusion data before the ROTEM analyser became available (Pre-ROTEM group). Blood product transfusion in the Pre-ROTEM group was guided by measurements of standard laboratory coagulation tests in conjunction with the established major haemorrhage protocols at the time. The findings indicate that the ROTEM analyser was effective in managing MOH at point-of-care and led to a reduction in the transfusion of CRC, FFP and platelets. However, contrary to published studies, the reduction in blood product usage was not accompanied by an increase in fibrinogen replacement transfusion therapy, suggesting that the ROTEM’s FIBTEM assay accurately quantified fibrinogen levels based on fibrin-clot firmness to enable an early diagnosis of hypofibrinogenemia. Early establishment of the absence of hypofibrinogenemia helped to prevent unnecessary transfusion of fibrinogen concentrate in this study. These findings support the adoption of routine use of ROTEM analysers at point-of-care on labour wards to manage MOH and reduce fibrinogen replacement therapy. The ease of use and rapidity of ROTEM tests could enable departure from globally directed correction of coagulopathy during MOH to a more focussed and precise target transfusion therapy, which will ultimately reduce blood product wastage (including fibrinogen concentrate) whilst minimising transfusion-associated side effects such as alloimmunisation, circulatory overload and dilutional coagulopathy.

Desmopressin Reduces Transfusion Needs after Surgery

2008 ◽  
Vol 109 (6) ◽  
pp. 1063-1076 ◽  
Author(s):  
Giuseppe Crescenzi ◽  
Giovanni Landoni ◽  
Giuseppe Biondi-Zoccai ◽  
Federico Pappalardo ◽  
Massimiliano Nuzzi ◽  
...  
Keyword(s):  
Blood Loss ◽  
Excess Mortality ◽  
Blood Product ◽  
Meta Analysis ◽  
Blood Product Transfusion ◽  
Blood Products ◽  
Hemostatic Agents ◽  
Randomized Controlled ◽  
Randomized Controlled Studies ◽  
Transfusion Requirements

Background Perioperative pathologic microvascular bleeding is associated with increased morbidity and mortality and could be reduced by hemostatic drugs. At the same time, safety concerns regarding existing hemostatic agents include excess mortality. Numerous trials investigating desmopressin have lacked power to detect a beneficial effect on transfusion of blood products. The authors performed a meta-analysis of 38 randomized, placebo-controlled trials (2,488 patients) investigating desmopressin in surgery and indicating at least perioperative blood loss or transfusion of blood products. Methods Pertinent studies were searched in BioMed Central, CENTRAL, and PubMed (updated May 1, 2008). Further hand or computerized searches involved recent (2003-2008) conference proceedings. Results In most of the included studies, 0.3 microg/kg desmopressin was used prophylactically over a 15- to 30-min period. In comparison with placebo, desmopressin was associated with reduced requirements of blood product transfusion (standardized mean difference = -0.29 [-0.52 to -0.06] units per patient; P = 0.01), which were more pronounced in the subgroup of noncardiac surgery and were without a statistically significant increase in thromboembolic adverse events (57/1,002 = 5.7% in the desmopressin group vs. 45/979 = 4.6% in the placebo group; P = 0.3). Conclusions Desmopressin slightly reduced blood loss (almost 80 ml per patient) and transfusion requirements (almost 0.3 units per patient) in surgical patients, without reduction in the proportion of patients who received transfusions. This meta-analysis suggests the importance of further large, randomized controlled studies using desmopressin in patients with or at risk of perioperative pathologic microvascular bleeding.

Major obstetric haemorrhageRachel Collis

2020 ◽  
pp. 469-492
Author(s):  
Collis
Keyword(s):  
Risk Assessment ◽  
Blood Loss ◽  
Early Recognition ◽  
Point Of Care ◽  
Trigger Points ◽  
Source Control ◽  
Team Members ◽  
Bleeding Management ◽  
Obstetric Haemorrhage ◽  
Specific Trigger

Successful management of major obstetric haemorrhage requires a multi-professional team to work together to avoid catastrophic consequences: obstetricians, anaesthetists, midwives, ODPs, theatre scrub staff, porters, as well as blood bank technicians and specialist haematologists. The key pillars of management include; antenatal risk assessment of all women, early recognition of haemorrhage, measured blood loss, prompt escalation at specific trigger points, i.e. >500ml, >1000ml, and review by senior team members to ensure rapid source control. This chapter explores the causes of bleeding, management steps based on algorithms from current practice, and latest evidence for use of point of care testing with visco-elastography for goal-directed control of early clotting failure.

scholarly journals How I use fibrinogen replacement therapy in acquired bleeding

Blood ◽  
2015 ◽  
Vol 125 (9) ◽  
pp. 1387-1393 ◽  
Author(s):  
Jerrold H. Levy ◽  
Lawrence T. Goodnough
Keyword(s):  
Replacement Therapy ◽  
Cardiovascular Surgery ◽  
Point Of Care ◽  
Critical Role ◽  
Clinical Settings ◽  
Point Of Care Testing ◽  
Hemostatic Therapy ◽  
Transfusion Guidelines ◽  
Fibrinogen Replacement Therapy

Abstract Fibrinogen is a critical protein for hemostasis and clot formation. However, transfusion guidelines have variable recommendations for maintaining fibrinogen levels in bleeding patients. An increasing number of studies support the practice of fibrinogen replacement therapy for acquired coagulopathies, and additional studies are underway. Fibrinogen therapy can be administered with cryoprecipitate or fibrinogen concentrates, and clinical practice varies according to their availability and licensing status. Fibrinogen concentrate therapy has been studied in animal models and clinical trials and supports the critical role of fibrinogen repletion in bleeding patients. Point-of-care testing will have an important role in guiding fibrinogen replacement for hemostatic therapy in clinical settings such as cardiovascular surgery, postpartum hemorrhage, and trauma. Fibrinogen therapy is an important component of a multimodal strategy for the treatment of coagulopathic bleeding.

Aprotinin for Patients Exposed to Clopidogrel before Off-Pump Coronary Bypass

2008 ◽  
Vol 16 (6) ◽  
pp. 483-487 ◽  
Author(s):  
Feza Nurözler ◽  
Tolga Kutlu ◽  
Güngör Küçük
Keyword(s):  
Coronary Artery ◽  
Blood Loss ◽  
Coronary Artery Bypass ◽  
Low Dose ◽  
Blood Product ◽  
Artery Bypass ◽  
Left Ventricular Ejection ◽  
Product Usage ◽  
Off Pump ◽  
Pump Coronary Artery Bypass

To verify whether low-dose aprotinin reduces blood loss and blood product usage in patients with clopidogrel exposure within 5 days before off-pump coronary artery bypass, 51 patients with clopidogrel exposure were randomized in a double-blind fashion to receive low-dose aprotinin (25 patients), or placebo (26 patients). The baseline characteristics and number of distal anastomoses in the patients in each group were comparable. Time between the last dose of clopidogrel and start of the operation was similar in both groups, as was mean left ventricular ejection fraction. Chest tube drainage, blood product usage, and reoperation rate were significantly higher in the placebo group. In patients with unstable angina and recent clopidogrel exposure who are undergoing off-pump coronary artery bypass, intraoperative administration of low-dose aprotinin is recommended to reduce blood loss and transfusion requirements.

ROTATIONAL THROMBOELASTOMETRY REDUCES BLOOD LOSS AND BLOOD PRODUCT USAGE AFTER LUNG TRANSPLANTATION

2021 ◽  
Author(s):  
Miroslav Durila ◽  
Jaromir Vajter ◽  
Michal Garaj ◽  
Lukas Pollert ◽  
Jan Berousek ◽  
...  
Keyword(s):  
Blood Loss ◽  
Lung Transplantation ◽  
Blood Product ◽  
Rotational Thromboelastometry ◽  
Product Usage

Point-of-Care Testing in Liver Disease and Liver Surgery

2017 ◽  
Vol 43 (04) ◽  
pp. 407-415 ◽  
Author(s):  
Lasitha Abeysundara ◽  
Susan Mallett ◽  
Ben Clevenger
Keyword(s):  
Liver Disease ◽  
Blood Product ◽  
Point Of Care ◽  
Massive Bleeding ◽  
Point Of Care Testing ◽  
Hemostatic System ◽  
Coagulation Tests ◽  
Postoperative Thrombosis ◽  
Coagulation Status ◽  
Point Of Care Tests

AbstractThe alterations in coagulation and hemostasis that accompany liver disease are complex, and while patients with this disease have traditionally been perceived as having a bleeding diathesis, it is now understood that in stable patients hemostasis is “re-balanced.” Hepatic surgery, and particularly liver transplantation, can be associated with large fluid shifts, massive bleeding, and coagulopathy, as well as postoperative thrombosis. Point-of-care tests (POCTs) of coagulation facilitate goal-directed treatments and hemostatic monitoring in dynamic environments where the coagulation status can alter rapidly and often unpredictably. POCTs reflect more accurately the re-balanced hemostatic system than do conventional coagulation tests (CCTs). Viscoelastic POCT-guided transfusion algorithms permit a reduction in blood product administration and are a key component of patient blood management programs. Moreover, viscoelastic POCTs are better able to identify patients with hypercoagulability than CCTs. With thrombosis increasingly recognized to be a problem in patients with liver disease, POCTs hold promise for both individualized bleeding and thrombosis management.

Point-of-Care Coagulation Testing in Cardiac Surgery

2017 ◽  
Vol 43 (04) ◽  
pp. 386-396 ◽  
Author(s):  
Kenichi Tanaka ◽  
Daniel Bolliger
Keyword(s):  
Cardiac Surgery ◽  
Point Of Care ◽  
Postoperative Bleeding ◽  
Blood Platelet ◽  
Heparin Therapy ◽  
Bleeding Complications ◽  
Treatment Algorithms ◽  
Product Usage ◽  
Coagulation Testing ◽  
Coagulation Tests

AbstractBleeding complications after cardiac surgery are common and are associated with increased morbidity and mortality. Their etiology is multifactorial, and treatment decisions are time sensitive. Point-of-care (POC) testing has an advantage over standard laboratory tests for faster turn-around times, and timely decision on coagulation intervention(s). The most common POC coagulation testing is the activated clotting time (ACT), used to monitor heparin therapy while on cardiopulmonary bypass. Viscoelastic coagulation tests including thromboelastometry (ROTEM) and thromboelastography (TEG) have been recommended for the treatment of postoperative bleeding after cardiac surgery because the ROTEM/TEG-guided treatment algorithms reduced the use of blood products. Other POC tests are commercially available, but there is sparse evidence for their routine use in cardiac surgery. These devices include heparin management systems, POC prothrombin time and activated partial thromboplastin time, POC fibrinogen assay, and whole blood platelet function tests. There are multiple confounding elements and conditions associated with cardiac surgery, which can significantly alter test results. Anemia and thrombocytopenia are regularly associated with deviations in many POC devices. In summary, POC coagulation testing allows for rapid clinical decisions in hematological interventions, and, when used in conjunction with a proper transfusion algorithm, may reduce blood product usage, and potentially complications associated with blood transfusion.

scholarly journals Blood management in post-partum haemorrhage, including point of care coagulation tests

2021 ◽  
Keyword(s):  
Early Recognition ◽  
Point Of Care ◽  
Post Partum ◽  
Coagulation Factor ◽  
Team Approach ◽  
Blood Products ◽  
Blood Management ◽  
Coagulation Tests ◽  
Haematological Changes ◽  
The Uk

Postpartum haemorrhage (PPH) is the leading global cause of maternal mortality, and an important cause of morbidity and mortality in the UK. Management of PPH requires a patient centred team approach to ensure effective management. Early recognition is crucial, hence quantitative measurement of blood loss should be started as soon as bleeding is identified and continue throughout an evolving haemorrhage. Pregnancy is associated with haematological changes resulting in a pro-coagulant state. Blood management in PPH has moved away from the use of shock packs and fixed transfusion ratios. Most women are not initially coagulopathic and coagulopathy is uncommon in mild to moderate PPH, Practice has therefore moved towards goal directed transfusion of blood products informed by haematological investigations alongside clinical assessment. Fibrinogen tends to be the first coagulation factor to fall and Clauss fibrinogen is an important predictor of PPH severity. Transfusion of fibrinogen rich blood products such as cryoprecipitate and fibrinogen complex are more effective at rapidly increasing fibrinogen levels compared to FFP. Point of care (POC) coagulation tests such as rotational thromboelastometry (ROTEM) and thromboeslastography (TEG) allow rapid bedside assessment compared to traditional laboratory tests. Surrogate markers of fibrinogen from POC tests can be used to both predict severity of PPH and inform blood transfusion. There is growing evidence that POC coagulation tests can be used to safely guide blood management in PPH, with its use associated with lower transfusion rates and possibly improved clinical outcomes. Further multi-centre studies are required to clarify debate surrounding their use. In this review we discuss blood management in PPH, with a focus on recent evidence regarding assessment of coagulopathy and the use of blood products.

scholarly journals Thromboelastography after Cardiopulmonary Bypass: Does it Save Blood Products?

2022 ◽  
Vol 15 (1) ◽  
pp. 341-344
Author(s):  
Omar Hasan ◽  
Robert Tung ◽  
Hadley Freeman ◽  
Whitney Taylor ◽  
Stephen Helmer ◽  
...  
Keyword(s):  
Cardiopulmonary Bypass ◽  
Blood Product ◽  
Tertiary Care ◽  
Length Of Hospital Stay ◽  
Fresh Frozen Plasma ◽  
Hospital Length Of Stay ◽  
Graft Occlusion ◽  
Blood Products ◽  
Care Community ◽  
Coagulation Tests

Introduction.  This study aimed to determine if thromboelastography (TEG) is associated with reduced blood product use and surgical re-intervention following cardiopulmonary bypass (CPB) compared to traditional coagulation tests. Methods.  A retrospective review was conducted of 698 patients who underwent CPB  at a tertiary-care, community-based, university-affiliated hospital from February 16, 2014 – February 16, 2015 (Period I) and May 16, 2015 - May 16, 2016 (Period II).  Traditional coagulation tests guided transfusion during Period I and TEG guided transfusion during Period II.  Intraoperative and postoperative administration blood products (red blood cells, fresh frozen plasma, platelets, and cryoprecipitate), reoperation for hemorrhage or graft occlusion, duration of mechanical ventilation, hospital length of stay and mortality were recorded.  Results.  Use of a TEG-directed algorithm was associated with a 13.5% absolute reduction in percentage of patients requiring blood products intraoperatively (48.2% vs. 34.7%, p <0.001).  TEG resulted in a 64.3% and 43.1% reduction in proportion of patients receiving FFP and platelets, respectively, with a 50% reduction in volume of FFP administered (0.3 vs. 0.6 units, p < 0.001).  Use of TEG was not observed to significantly decrease postoperative blood product usage or mortality.  The median length of hospital stay was reduced by 1 day after TEG guided transfusion was implemented (nine days vs. eight days, p = 0.01). Conclusions.  Use of TEG-directed transfusion of blood products following CPB appears to decrease the need for intraoperative transfusions, but the effect on clinical outcomes has yet to be clearly determined.

scholarly journals Blood Transfusion in Obstetric Cases

2020 ◽  
pp. 197-200
Author(s):  
Ali Sungkar ◽  
Raymond Surya
Keyword(s):  
Blood Transfusion ◽  
Blood Loss ◽  
Massive Transfusion ◽  
Patient Blood Management ◽  
Blood Products ◽  
Blood Management ◽  
Transfusion Therapy ◽  
Massive Transfusion Protocol ◽  
Life Threatening ◽  
Transfusion Protocol

Objective: To discuss about blood loss in an obstetric setting, the role of blood transfusion, and patient blood management.Methods: Literature review.Results: Severe anaemia with hemoglobin level less than 7 g/dL or late gestation (more than 34 weeks) and/ or significant symptoms of anaemia, the recommendation is giving only single unit transfusion followed by clinical reassessment for further transfusion. In postpartum hemorrhage (PPH), massive transfusion protocols are commonly used description as large volume of blood products over a brief period to a patient with uncontrolled or severe hemorrhage, transfusion more than 10 RBC units within 24 hours, transfusion more than 4 RBC units in 1 hour with anticipation of continued need for blood, replacement of more than 50% of total blood volume by blood products within 3 hours. All obstetric units have a clear-cut massive transfusion protocol for the initial management of life-threatening PPH, considering early transfusion therapy with RBCs and FFP.Conclusion: Patient blood management aims to maintain hemoglobin concentration, optimize haemostasis, and minimize blood loss in effort to improve patient outcomes. Massive transfusion protocol in management of life-threatening should depend on each obstetric unit.Keywords: blood transfusion, obstetric cases, patient blood management.   Abstrak Tujuan: Untuk mendiskusikan tentang hilang darah dalam obstetric, peran transfusi darah, dan patient blood management.Metode: Kajian pustaka.Hasil: Anemia berat dengan nilai hemoglobin kurang dari 7 g/dL atau kehamilan lanjut (lebih dari 34 minggu) dan/ atau gejala nyata anemia, rekomendasi ialah memberikan satu unit transfusi diikuti dengan penilainan klinis untuk transfusi lebih lanjut. Pada perdarahan postpartum, protokol transfusi massif umum digambarkan sebagai volume darah yang dibutuhkan jumlah banyak dalam periode singkat, transfusi lebih dari 10 sel darah merah dalam 24 jam atau lebih dari 1 jam, penggantian lebih dari 50% total volume darah dalam 3 jam. Seluruh unit obstetric memiliki protokol transfusi massif yang jelas untuk taalaksana awal perdarahan postpartum dengan mempertimbangkan transfusi awal untuk komponen sel darah merah dan FFP.Kesimpulan: Patient blood management bertujuan untuk menjaga konsentrasi hemoglobin, optimalisasi hemostasis, dan minimalisasi hilang darah untuk meningkatkan luaran pasien. Protokol transfusi masfi dalam tatalaksana yang mengancam nyawa sangat bergantung pada setiap unit obstetrik.Kata kunci: kasus obstetri, patient blood management, transfusi darah  

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