ABO Blood Group and RhD status Are Not Associated with Mortality and Morbidity in Critically Ill Patients; a Multicentre Observational Study of 29 512 Patients

Background. Previous studies have demonstrated an association between ABO blood groups and many types of disease. The present study primarily aimed to identify associations between ABO blood groups, RhD groups and mortality/morbidity outcomes in critically ill patients both in a main cohort and in six pre-defined subgroups. The secondary aim was to investigate any differences in transfusion requirement between the different ABO blood groups and RhD status.Methods. Adult patients admitted to any of the five intensive care units (ICUs) in Skåne, Sweden, between February 2007 and April 2021 were eligible for inclusion. The outcomes were mortality analysed at 28– and 90–days as well as at the end of observation and morbidity measured using days alive and free of (DAF) invasive ventilation (DAF ventilation) and DAF circulatory support, including vasopressors or inotropes (DAF circulation), maximum Sequential Organ Failure Assessment score (SOFAmax) the first 28 days after admission and length of stay. All outcomes were analysed in separate multivariable regression models (adjusted for age and sex), generating odds or hazard ratios for each blood group and RhD status using blood group O and RhD negative as reference. Transfusion requirements were also investigated.Results. In total, 29 512 unique patients were included in the analyses. There were no significant differences for any of the outcomes between non-O blood groups and blood group O, or between RhD groups. In five pre-defined subgroups (sepsis, septic shock, acute respiratory distress syndrome, cardiac arrest and trauma) there were no differences in mortality between non-O blood groups and blood group O or between the RhD groups. The Covid-19 cohort was not investigated given the low number of patients. Furthermore, we could not demonstrate any differences in the number of transfused patients between the ABO blood groups or between the RhD groups.Conclusions. ABO blood type and RhD status do not appear to influence mortality or morbidity in a general critically ill patient population. There were no differences in the number of transfused patients between the ABO blood groups or between the RhD status groups.

Neuroprotective strategies with circulatory arrest in open aortic surgery – A meta-analysis

Objective Deep hypothermic circulatory arrest (DHCA) in aortic surgery is associated with morbidity and mortality despite evolving strategies. With the advent of antegrade cerebral perfusion (ACP), moderate hypothermic circulatory arrest (MHCA) was reported to have better outcomes than DHCA. There is no standardised guideline or consensus regarding the hypothermic strategies to be employed in open aortic surgery. Meta-analysis was performed comparing DHCA with MHCA + ACP in patients having aortic surgery. Methods A systematic review of the literature was undertaken. Any studies with DHCA versus MHCA + ACP in aortic surgeries were selected according to specific inclusion criteria and analysed to generate summative data. Statistical analysis was performed using STATS Direct. The primary outcomes were hospital mortality and post-operative stroke. Secondary outcomes were cardiopulmonary bypass time (CPB), post-operative blood transfusion, length of ICU stay, respiratory complications, renal failure and length of hospital stay. Subgroup analysis of primary outcomes for Arch surgery alone was also performed. Results Fifteen studies were included with a total of 5869 patients. There was significantly reduced mortality (Pooled OR = +0.64, 95% CI = +0.49 to +0.83; p = 0.0006) and stroke rate (Pooled OR = +0.62, 95% CI = +0.49 to +0.79; p < 0.001) in the MHCA group. MHCA was associated significantly with shorter CPB times, shorter duration in ICU, less pulmonary complications, and reduced rates of sepsis. There was no statistical difference between the two groups in terms of circulatory arrest times, X-Clamp times, total operation duration, transfusion requirements, renal failure and post-op hospital stay. Conclusion MHCA + ACP are associated with significantly better post-operative outcomes compared with DHCA for both mortality and stroke and majority of the secondary outcomes.

Reduction in blood product transfusion requirements with early on-ECMO repair of congenital diaphragmatic hernia

Background For infants with severe congenital diaphragmatic hernia (CDH) stabilized with extracorporeal membrane oxygenation (ECMO), early repair on ECMO improves outcome; however when compared to operative repair after ECMO, repair on ECMO is associated with increase bleeding risk and need for blood product transfusions. Methods A retrospective review of 54 patients with CDH placed on ECMO prior to CDH repair was performed. For the subset of patients repaired on ECMO, analysis comparing those repaired early (within 48 h of cannulation) and late (beyond 48 h) on ECMO was performed. Outcomes of interest included survival to discharge, days on ECMO, and postoperative blood product utilization. Results When compared to those patients repaired prior to 48 h of ECMO initiation, 57.7% of patients survived versus 40.9% of late repair patients. For those repaired early, blood product utilization was significantly less. Early repair patients received a median of 72 mL/kg packed red blood cells (PRBC) and 75 mL/kg platelets compared to 151.9 mL/kg and 98.7 mL/kg, respectively (p < 0.05 respectively). There was no difference in median days on ECMO (p = 0.38). Conclusion Our data supports prior reports of improved outcome with repair with 48 h of ECMO initiation and suggests early repair on ECMO is associated with less bleeding and decreased blood product requirement in the postoperative period.

Medical management versus surgical management in fibroid uterus

Background: Uterine fibroids (leiomyomas) are most common tumours of the uterine smooth muscles, appear to increase in incidence with age during reproductive years, with a peak in incidence between 35 to 40 years. Signs and symptoms of uterine fibroids include heavy or prolonged menstrual bleeding, pain and pregnancy complications. Current management strategies mainly involve surgical interventions, but choice of treatment is guided by patient’s age and desire to preserve fertility or avoid ‘radical’ surgery such as hysterectomy.Methods: It is the prospective observational study conducted in inpatients of department of OBGY at tertiary care hospital, admitted during the period of June 2019 to May 2021. Outcome measured in terms of relief of symptoms, decrease in size of fibroid, requiring subsequent surgery, quality of life, blood transfusion requirements, length of stay in hospital, successful pregnanciesResults: Of patients treated with ulipristal, 78.57% had improved quality of life, in patients treated with leuprolide, 57.14% showed improved quality of life, with mifepristone 80% patients showed improved quality of life and with LNG 100% patients responded to it. All patients treated surgically, showed relief of symptoms.Conclusions: Medical line of management is best for patients in younger age group, small size fibroid, desire for future fertility. Uterus sparing option like myomectomy is done in patients not responding to medical line of management and desire for future fertility. Hysterectomy is definitive line of management for patients with fibroid uterus.

Neuroblastoma in Children: Intraoperative Goal Directed Therapy, Intraoperative And Postoperative Outcomes

Background: Neuroblastoma is the most common tumor in children. Anesthetic management can be challenging due to the localization and catecholamine-secreting characteristics of the tumor. We undertook a secondary analysis in a previous study to describe patients who underwent neuroblastoma resection.Objective: To describe intraoperative and postoperative outcomes in patients who underwent neuroblastoma resection and to propose optimal intraoperative management for postoperative outcome improvement.Methods: This was a secondary analysis of children who underwent neuroblastoma resection in the initial retrospective study.Results: There were 16 patients with a mean age of 39.3±22.1 months. Seven (43.8%) patients presented with intraoperative or postoperative complications. One (6.3%) patient had intraoperative broncholaryngospasm and difficult intubation. Two (12.5%) patients had intraoperative hemorrhagic shock. One patient (6.3%) had postoperative renal failure. Two patients (12.5%) had postoperative respiratory failure, and 3 (18.8%) patients had postoperative cardiocirculatory failure. One (6.3%) had postoperative pulmonary sepsis and septicemia. Thirteen (81.3%) patients were intraoperatively transfused. There was no in-hospital mortality.Conclusion: In this cohort, 43.8% of the patients had intraoperative and/or postoperative complications in terms of organ dysfunction or sepsis. A total of 81.3% of the patients received intraoperative transfusion. Neuroblastoma surgery can be a challenging situation where cardiovascular instability, high blood loss and transfusion requirements can be encountered. Consequently, preoperative preparation and optimal intraoperative management with validated tools in children could be necessary for a better postoperative outcome in this surgical setting.

Fibrinogen and Bleeding in Adult Cardiac Surgery: A Review of the Literature

Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings.

Pathophysiology of Coagulopathy Induced by Traumatic Brain Injury Is Identical to That of Disseminated Intravascular Coagulation With Hyperfibrinolysis

Background: Traumatic brain injury (TBI)-associated coagulopathy is a widely recognized risk factor for secondary brain damage and contributes to poor clinical outcomes. Various theories, including disseminated intravascular coagulation (DIC), have been proposed regarding its pathomechanisms; no consensus has been reached thus far. This study aimed to elucidate the pathophysiology of TBI-induced coagulopathy by comparing coagulofibrinolytic changes in isolated TBI (iTBI) to those in non-TBI, to determine the associated factors, and identify the clinical significance of DIC diagnosis in patients with iTBI.Methods: This secondary multicenter, prospective study assessed patients with severe trauma. iTBI was defined as Abbreviated Injury Scale (AIS) scores ≥4 in the head and neck, and ≤2 in other body parts. Non-TBI was defined as AIS scores ≥4 in single body parts other than the head and neck, and the absence of AIS scores ≥3 in any other trauma-affected parts. Specific biomarkers for thrombin and plasmin generation, anticoagulation, and fibrinolysis inhibition were measured at the presentation to the emergency department (0 h) and 3 h after arrival.Results: We analyzed 34 iTBI and 40 non-TBI patients. Baseline characteristics, transfusion requirements and in-hospital mortality did not significantly differ between groups. The changes in coagulation/fibrinolysis-related biomarkers were similar. Lactate levels in the iTBI group positively correlated with DIC scores (rho = −0.441, p = 0.017), but not with blood pressure (rho = −0.098, p = 0.614). Multiple logistic regression analyses revealed that the injury severity score was an independent predictor of DIC development in patients with iTBI (odds ratio = 1.237, p = 0.018). Patients with iTBI were further subdivided into two groups: DIC (n = 15) and non-DIC (n = 19) groups. Marked thrombin and plasmin generation were observed in all patients with iTBI, especially those with DIC. Patients with iTBI and DIC had higher requirements for massive transfusion and emergency surgery, and higher in-hospital mortality than those without DIC. Furthermore, DIC development significantly correlated with poor hospital survival; DIC scores at 0 h were predictive of in-hospital mortality.Conclusions: Coagulofibrinolytic changes in iTBI and non-TBI patients were identical, and consistent with the pathophysiology of DIC. DIC diagnosis in the early phase of TBI is key in predicting the outcomes of severe TBI.