Hemolysis in a Patient during Hemodialysis

We report a case of hemolysis during a hemodialysis (HD) session in a 71-year-old man. His end-stage kidney disease is secondary to light-chain amyloidosis with renal involvement. Despite immunosuppressive treatment, his renal function continued to decline, and dialysis had to be initiated. Peritoneal dialysis (PD) was started but that had to be converted to HD because of pleural effusion due to PD fluid leakage. On the event day, the patient presented a respiratory distress 2 h after the initiation of HD. He developed a sudden onset of dyspnea with hypoxemia, associated with abdominal pain, nausea, and vomiting. He also presented chest pain with arterial hypertension. The pre-pump arterial and post-pump pressures were, respectively, 40 and 100 mm Hg, with no machine alarm. The blood color in the circuit changed and became darker, so HD was stopped immediately without blood restitution, and then a blood workup was obtained, and the patient was treated with oxygen therapy, IV methylprednisolone 40 mg, and IV furosemide 100 mg. Tubing checkup performed after the incident showed a kinked arterial tube which led to the suspicion of acute hemolysis. Blood transfusion was therefore urgently ordered, and the patient was immediately transferred to the intensive care unit (ICU). Artificial ventilation was required for 4 days, with initial massive blood transfusion. A 24-h treatment with extracorporeal cytokine adsorber CytoSorb^® was also performed, followed by the regular HD sessions thrice weekly. Evolution was favorable, and the patient was discharged from the ICU 18 days later.

Blood products and fluid therapy

This chapter describes the blood products which are commonly required as part of anaesthetic practice, including red cells, plasma, cryoprecipitate, platelet concentrate, and concentrated coagulation factor preparations. The essential components of patient blood management, aiming to reduce the requirement for transfusion, are described. The principles and practice of massive blood transfusion are described. The specific management of Jehovah’s Witnesses, and other patients who decline blood transfusion, is discussed. The chapter finishes with a discussion of the common intravenous fluid preparations which are used in practice, and how to use them appropriately.

Massive Transfusion Protocol Over-Activation

Introduction/Objective Massive blood transfusion protocol (MTP) is revealed in many cases, such as massive hemorrhage after surgeries, trauma settings, and labor and delivery. Patients who require blood transfusion of more than ten units of packed red blood cells in 24 hours or transfusion of more than four units of packed red blood cells (PRBCs) in one hour are the massive blood transfusion protocol candidates. Methods/Case Report A retrospective study was performed at a 225-bed level III trauma center in California. The overall massive blood transfusion protocol utilization, blood product emergency release, and blood product waste were recorded twelve months before and after launching an educational and collaboration program between blood banks and clinicians about the difference between massive transfusion protocol and blood emergency release. Results (if a Case Study enter NA) MTP utilization for the 12 months (June 2017 to June 2018) was demonstrated as 59 MTP activations: 32 MTPs from the emergency department, 4 MTPs from inpatient floors, 3 MTPs from labor and delivery, and 4 MTPs from operating rooms while the blood product emergency releases were 7 emergency releases. MTP utilization from (June 2018 to June 2019) was demonstrated as 15 MTP activations: 11 MTPs from the emergency department, 2 MTPs from inpatient floors, 1 MTPs from labor and delivery, and 1 MTPs from operating rooms, while the blood product emergency releases were 43 emergency releases. The blood product waste was reduced by 44.6% in 2018. Conclusion There was a significant reduction in MTP activation and blood product waste after implementing the educational program for the clinicians. The collaboration between the blood bank and the clinicians and coordinating educational sessions for clinicians about the difference between MTP and emergency release and the negative impact of the MTP over-activation on the blood product waste and the clinical laboratory scientists in the blood bank is vital in MTP utilization.

Incidence, trends and risk factors for obstetric massive blood transfusion in China from 2012 to 2019: an observational study

ObjectivesThis study aims to use the high-quality national monitoring data from the China’s National Maternal Near Miss Surveillance System (NMNMSS) to ascertain the incidence, trends and risk factors of obstetric massive blood transfusion (MBT) from 2012 to 2019 in China and determine its clinical outcomes.SettingsObservational study of hospitalised pregnancies who had given birth or ended their pregnancy among member hospitals of NMNMSS.Participants11 667 406 women were included in this study.Primary and secondary outcome measuresWe screened for the incidence, trends, risk factors and main reasons for obstetric MBT, and the outcomes after obstetric MBT. MBT was defined as the transfusion of ≥5 units of red blood cells or ≥1000 mL of whole blood. The incidence of MBT was defined as the MBT cases per 10 000 pregnancies.ResultsObstetric MBT occurred in 27 626 cases, corresponding to an incidence of 23.68 per 10 000 maternities, which exhibited an increasing trend in China during 2012–2019 (14.03–29.59 per 10 000 maternities, p for trend <0.001). Obstetric MBT was mainly associated with amniotic fluid embolism, uterine atony, abnormal placenta, severe anaemia, ectopic pregnancy, abortion, caesarean section, advanced maternal age and multiparous from biological effect. While from sociological effects, uterine atony, severe anaemia and placenta previa are the top three complications which more likely to undergo obstetric MBT in the Chinese population. Overall, the secular trends of hysterectomy incidence (25.07%–9.92%) and MMR during hospitalisation (21.41‰–7.48‰) among women who underwent MBT showed decreasing trends (p for trend <0.001).ConclusionTo minimise the incidence of obstetric MBT, more attention should be paid to education on the importance of the antenatal visit, evidence-based transfusion practice and females who are multiparous and have an advanced age, amniotic fluid embolism, uterine atony, severe anaemia and placenta previa.

Peripartum cardiomyopathy and massive transfusion due to postpartum hemorrhage: was it associated with each other?

Background: Peripartum cardiomyopathy (PPCM) is a potentially life-threatening pregnancy-associated disease marked by left ventricular dysfunction and heart failure (HF). Clinical findings of HF are often masked by the normal physiological changes seen in pregnancy, making the diagnosis challenging. Furthermore, postpartum hemorrhage followed by massive blood transfusion may mask the diagnosis of PPCM or worsen the decompensated HF. Case Description: We report a 35-year-old postpartum gemelli woman with a history of massive postpartum hemorrhage due to atonia uteri and Disseminated Intravascular Coagulation, complain of shortness of breath and fever. The patient received a massive blood transfusion for her massive postpartum hemorrhage. Physical examination revealed tachypnea and bilateral rales at lung bases. Chest radiographs showed cardiomegaly, right pleural effusion, and early lung edema. The echocardiography showed a decrease in left ventricular systolic function with ejection fraction of 41%, diastolic dysfunction, and global hypokinetic. She was diagnosed with PPCM, acute lung edema, pleural effusion, and pneumonia. Patient was treated with Furosemide continuous pump, Spironolactone, Bisoprolol, Valsartan. Her dyspnea greatly decrased with diuresis and antibiotic. She was discharged with HF medication continued. Discussion: Women with PPCM typically present with symptoms of HF and signs of congestion. History of massive blood transfusion at first can mask the diagnosis of PPCM due to the possibility of Transfusion Associated Circulatory Overload, which also has signs of congestion. Massive blood transfusion can increase preload and may worsen the decompensated HF. Conclusion: The presence of massive transfusion in a patient with PPCM can be challenging in diagnosing PPCM itself and the unpredictable course of decompensated HF in peripartum mothers. Due to its high mortality rate without proper treatment, prompt investigation is essential in improving maternal survival.

Maternal near miss, mortality and their correlates at tertiary care hospital

ABSTRACT OBJECTIVE: To determine the frequency and causes of maternal near miss and mortality among pregnant women. METHODS: This cross-sectional study was conducted Jan 2016 - Dec 2018. All near miss cases, admitted in Gynecology department of Services Hospital Lahore during the study period, were prospectively recruited. WHO criteria was used to identify maternal near miss cases. Primary outcome measures were frequency and causes of near miss and maternal mortality to near miss ratio. Secondary outcome measures were delays, need for massive blood transfusion, ICU admission, obstetric hysterectomy and hospital stay> 7 days. RESULTS: During the study period, there were 10,739 live births, 305 near miss cases and 29 maternal deaths. Frequency of near miss was 28.4/ 1000 live births and maternal mortality to near miss ratio was 1:10.5. There were 215(70.4%) unbooked patients and 23(79.3%) of them died (p<0.001). Hemorrhage accounted for 150 (49.18%), hypertensive disorders 102 (33.44%),cardiac disease 25 (8.28%) and infection for 12 (3.97%) near miss cases respectively. Maternal mortality was significantly low for hemorrhage, hypertension, sepsis and cardiac disease; 6 vs 150, 8 vs102, 3vs 12 and 10 vs 25 respectively (p<0.001). Massive blood transfusion was given to 20.98%patients, 15.74% underwent hysterectomy, 32.13% required ICU admission. First and second delay was seen in 78.6% of patients with 86.2% deaths (p<0.001) CONCLUSION: Hemorrhage and hypertension are major reasons for near miss but timely intervention can prevent mortality. Strengthening care at primary and secondary level can reduce the burden of maternal morbidity. Continuous....

Massive Blood Transfusion for Trauma Score to Predict Massive Blood Transfusion in Trauma

Background. Massive blood loss is the most common cause of immediate death in trauma. A massive blood transfusion (MBT) score is a prediction tool to activate blood banks to prepare blood products. The previously published scoring systems were mostly developed from settings that had mature prehospital systems which may lead to a failure to validate in settings with immature prehospital systems. This research aimed to develop a massive blood transfusion for trauma (MBTT) score that is able to predict MBT in settings that have immature prehospital care. Methods. This study was a retrospective cohort that collected data from trauma patients who met the trauma team activation criteria. The predicting parameters included in the analysis were retrieved from the history, physical examination, and initial laboratory results. The significant parameters from a multivariable analysis were used to develop a clinical scoring system. The discrimination was evaluated by the area under a receiver operating characteristic (AuROC) curve. The calibration was demonstrated with Hosmer–Lemeshow goodness of fit, and an internal validation was done. Results. Among 867 patients, 102 (11.8%) patients received MBT. Four factors were associated with MBT: a score of 3 for age ≥60 years; 2.5 for base excess ≤–10 mEq/L; 2 for lactate >4 mmol/L; and 1 for heart rate ≥105 /min. The AuROC was 0.85 (95% CI: 0.78–0.91). At the cut point of ≥4, the positive likelihood ratio of the score was 6.72 (95% CI: 4.7–9.6, p < 0.001), the sensitivity was 63.6%, and the specificity was 90.5%. Internal validation with bootstrap replications had an AuROC of 0.83 (95% CI: 0.75–0.91). Conclusions. The MBTT score has good discrimination to predict MBT with simple and rapidly obtainable parameters.