Australian doctors fight over HIV testing.

Aims & Objectives: Liberal use of blood products in extracorporeal membrane oxygenation (ECMO) patients does not improve survival rates. We audited local clinical practice changes after update of ECMO guidelines on anti-coagulation and use of blood and blood products. Methods We compared frequency of blood sampling and use of blood products pre-January 2016 (Group 1) and post-January 2016 (Group 2) in children on ECMO. Key changes introduced in January 2016 included a. Reduction in blood count/chemistry sampling frequency from 4–6 hourly to 2/day; b. No routine blood cultures and antithrombin III measurements during ECMO; c. ACT monitoring 1hrly to 2-4hrly when stable. Threshold for blood transfusion remained as per PICU protocol. Additional sampling only if clinically indicated. Results Group 1: 13 consecutive ECMO runs (11 patients; median age: 0.6 months); Group 2: 13 consecutive ECMO runs (13 patients; median age: 8 months). Both groups had 6 patients each with univentricular circulation. There was significant reduction in the number of blood samples:132 (group 1) vs 67 (group 2). There was significant reduction in the use of blood products (ml/kg). Packed Red Cells: 255 vs 65; Fresh Frozen Plasma: 118 vs 50; Cryoprecipitate: 35 vs 15; Platelets: 122 vs 70 in groups 1 and 2 respectively. 3/11(28%) in Group 1 and 9/13(69%) in Group 2 survived PICU discharge. However, this audit did not evaluate factors for mortality in ECMO patients. Conclusions It is feasible to rationalise and reduce blood product usage in paediatric ECMO patients without increasing mortality. We will evaluate donor exposure and financial implications.

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality. Little is known about transfusion practices in patients requiring blood tansfusions following cesarean delivery. The objective of this study is to describe the use of blood products, clotting factors, colloids, and antifibrinolytics in a contemporary cohort of patients with hemorrhage during cesarean and compare blood product use with a historic cohort of patients with a similar diagnosis. Secondary analysis of a multicenter trial of tranexamic acid versus placebo to prevent PPH during cesarean delivery. Patients with qualitative estimated intraoperative blood loss (EBL) of more than 1 L were included in this analysis. Variables analyzed included transfusion of blood products, ratio of transfused packed red blood cell (PRBC) to fresh frozen plasma (FFP) and platelets, and use of clotting factors, anti-fibrinolytics, and colloids. Transfusion strategies were also compared with a historic cohort from the APEX study. Of the 707 (7.7%) who had EBL of greater than 1 liter, packed red cells were transfused in 21.1%, FFP in 5.4%, platelets in 2.4%, and cryoprecipitate in 2.3%. Among patients who received both PRBC and FFP, three quarters had a PRBC:FFP ratio between 1:1 and 2:1. Patients receiving both PRBC and platelets had a 1:1 ratio or less in 76.5% of cases. Clotting factor concentrates were not used in any case. Albumin was administered in 10.2% of cases. When compared with the historic cohort with an EBL > 1 L during cesarean, no differences in the use of blood products was noted. 1 in 5 patients with intraoperative EBL > 1 L received PRBC transfusion. The use of other blood products was rare. There was no difference in transfusion strategies overtime when compared with a similar historic cohort. Obstetrical hemorrhage in patients undergoing cesarean delivery rarely involves intensive transfusion therapy. · A total of 21% of patients with hemorrhage during cesarean received packed red cells.. · Use of other blood products was rare.. · Pathological activation of the clotting cascade is unlikely.. · No difference in transfusion strategies was noted overtime..

Explaining the excess morbidity of emergency general surgery: packed red blood cell and fresh frozen plasma transfusion practices are associated with major complications in nonmassively transfused patients

To report the outcomes over 14 years of sustained systematic institutional focus on the care of women with major obstetric hemorrhage, defined as estimated blood loss greater than 1,500 mL. A retrospective cohort study of women with major obstetric hemorrhage at our hospital from 2000 to 2014 compares baseline conditions (age, multiparity, prior cesarean delivery, morbidly adherent placenta), morbidity (lowest mean temperature, lowest mean pH, coagulopathy, hysterectomy), and mortality among three time periods (period 1=January 2000 to December 2001, period 2=January 2002 to August 2005, period 3=September 2005 to December 2014). We also describe the systematic changes that helped to sustain our improved outcomes. During the three time periods, there were 5,811, 12,912, and 38,971 births; the rate of major obstetric hemorrhage increased over these periods: 2.1, 3.8 and 5.3 cases per 1,000 births, respectively. Two deaths from hemorrhage occurred in period 1 and none thereafter. Among women who experienced massive hemorrhage, morbidity significantly improved in each successive period: median lowest pH increased from 7.23 to 7.34 to 7.35 (periods 2 and 3 significantly higher than period 1), median lowest maternal temperature (°C) improved, 35.2 to 36.1 to 36.4 (all difference significant), and the rate of coagulopathy decreased, 58.3% to 28.6% to 13.2% (period 3 significantly lower than periods 1 and 2) (all P values <.001). Peripartum hysterectomies were more frequent and more frequently planned over time rather than urgent in each successive period: 0 of 6 to 6 of 18 (33%) to 31 of 64 (48.4%) (P=.044). During period 3, we reorganized the obstetric rapid response team, instituted a massive transfusion protocol and use of uterine balloon tamponade, and promoted a culture of safety in two ways-through more intensive education regarding hemorrhage and escalation (encouraging all staff to contact senior leaders). A sustained level of patient safety is achievable when treating major obstetric hemorrhage, as shown by a progressive decrease in morbidity despite increasing rates of hemorrhage.

BackgroundThe primary cause of preventable trauma-related death is major haemorrhage. Activation of a Massive Transfusion Protocol (MTP) or ‘Code Red’ initiates the rapid and continuous supply of a large volume...

Defining the learning curve in CT-guided navigated thoracoscopic vertebral body tethering.

Central venous pressure and liver resection: a systematic review and meta analysis

Most patients with myelodysplastic syndrome (MDS) require blood product support to manage the severe anaemias, which frequently accompany MDS. Our objective was to show the feasibility of linking the Surveillance, Epidemiology and End Results (SEER) database with records from Puget Sound Blood Center (PSBC) to characterize blood product use over time in successive cohorts of patients with MDS. We identified patients with MDS in the SEER registry. The cohort was then linked to PSBC records to discern blood product use. Included in the analysis were 783 patients with MDS entered in the SEER database from 2001 to 2007 for whom data were also available in the PSBC database. Among patients with MDS who received transfusions, 97% received packed red blood cells; 52% received platelets. The proportion of patients with MDS receiving blood products declined from 2001 to 2007. These data show a recent decline in blood product use for patients with MDS. Future studies are needed to further evaluate the reasons for this finding, specifically exploring the impact of newer medications on blood product use in patients with MDS.

Anaesthetic drugs and procedures interfere with secondary brain injury following severe head trauma, yet studies regarding the anaesthetic management of these patients are lacking. We investigated the behaviour of Italian anaesthetists regarding this topic. A questionnaire investigating the approach to a patient with severe head trauma requiring an urgent splenectomy for ruptured spleen was sent to 250 Italian anaesthetists. Questions regarded the pre-, intra- and postoperative phases, and concerned the rationale use and availability of specific monitoring systems, and indications for invasive procedures and use of drugs, fluids and blood products. There were 162 (64.8%) responders. Seventy-five percent believed that early tracheal intubation within the emergency room was necessary, while 25% postponed it to the operating room. Basic monitoring was defined as essential by all responders, 147 (90.7%) considered invasive arterial pressure monitoring to be essential. Fifty-seven (84%) anaesthetists working in hospitals without neurosurgical facilities would have transferred the patient after splenectomy. Prophylactic hyperventilation was frequently used (36%). Sixty-eight percent of responders would have preferred in intracranial pressure monitoring inserted before laparotomy, but only 35% actually had this possibility. In case of acute intraoperative arterial hypotension after splenectomy, 54% of the responders advocated the use of blood or blood products to optimize peripheral oxygen transport. More widespread knowledge of certain areas of severe head trauma management such as early tracheal intubation, avoidance of prophylactic hyperventilation, adequate invasive monitoring, appropriate use of blood products, and timing of transfer to hospitals with neurosurgical facilities is needed.

Blood Products and the Phases of Perianesthesia Care—Reviewing the Implications

Pernicious placenta previa (PPP) is the main cause of severe obstetric postpartum hemorrhage and hysterectomy and often requires donor blood transfusion. Prophylactic internal iliac artery (IIA) balloon occlusion (BO) combined with cell salvage is increasingly being deployed in parallel transverse uterine incision (PTUI) cesarean section (CS). The aim of this study was to explore the differences in blood management in PTUI CS with or without prophylactic IIA BO and to evaluate the safety and efficacy of cell salvage to reduce the need for donor blood transfusion during PTUI CS.This retrospective study included all women who were diagnosed with PPP and PA and underwent PTUI CS from October 1, 2016, to October 31, 2018. Sixty-four patients were included: 34 underwent prophylactic IIA BO (IIA group), whereas 30 were treated without prophylactic IIA BO (control group). The primary outcome was a composite measure of perioperative blood management outcomes, including the estimated blood loss (EBL), donor blood transfusion, salvaged blood returned, fresh frozen plasma (FFP), pre- and postoperative serum hemoglobin and hematocrit. In addition, the baseline conditions of mother and neonates were compared.EBL was significantly higher in the IIA group compared to the control group (2883.5 mL in the IIA group vs 1868.7 mL in the control group, P = .001). Overall, the donor blood transfusion rate was 23.5% (8/34), averaging 4.2 U, in the IIA group versus 30% (9/30), averaging 3.4 U, in the control group, which were not significantly different. The FFP transfusion rate was 47%, averaging 765.6 mL, in the IIA group versus 20%, averaging 816.7 mL, in the control group. In the IIA group, 97.1% used cell savage and had salvaged blood returned, averaging 954.9 mL. In the control group, 90% had salvaged blood returned, averaging 617.9 mL. No cases of amniotic fluid embolism were observed with leukocyte depletion filters.Prophylactic IIA BO during PTUI CS in women with PPP and PA does not lead to a statistically significant reduction in EBL. Cell salvage was associated with a reduction in the rate of donor blood transfusion during PTUI CS.

BackgroundBlood products are a lifesaving commodity in the treatment of major trauma.Although there is little evidence for use of pre-hospital blood products (PHBP) in seriously injured patients, an increasing number of emergency medical services have started using PHBP for treatment of major haemorrhage.The primary aim of this survey was to establish the degree of prehospital blood product use throughout Europe and discover main indications. The secondary aim was to evaluate opinions about PHBP and also the experience and the personal views of its users.MethodsThe subcommittee for Critical Emergency Medicine of the European Society of Anaesthesiology (ESA) held an online survey of European Helicopter Emergency Services (HEMS) and all French Services d’Aide Médicale Urgente (SAMU) regions. It contained 13 questions both open and multiple-choice about the frequency transfusions are carried out, the PHBP used and the perceived benefit. The survey was distributed to the corresponding HEMS leads in 14 European countries.ResultsIn total there were 172 valid responses; overall 48% of all respondents have prehospital access to packed red cells, 22% to fresh plasma and 14% use lyophilised plasma. Besides blood product administration, 94% of all services use tranexamic acid. Sixty five percent of all replies came from French and from German services (37 and 28% respectively). PHBP were mainly used for trauma related emergencies. France has the highest uptake of use of blood products at 89%, whereas the rate in Germany was far lower at 6%.Fifty five percent of the service leads felt that PHBP are beneficial, and even lifesaving in individual cases despite being needed infrequently.ConclusionsWe found remarkable dissimilarities in practice between the different European countries. Even if there is not an absolute consensus amongst providers on the benefit of PHBP, the majority feel they are beneficial. The difference in practice is possibly related to the perceived lack of evidence on prehospital blood transfusion. We suggest to include the use of PHBP in trauma registries in order to consolidate the existing evidence.

Bloodless surgery and a reduction in the use of allogeneic blood products has long been the standard of care in medicine. Many individuals in our communities have demanded this form of surgical treatment for personal and religious reasons. On 6 December 2002, a 72-year-old male patient was admitted to our institution as a critical air flight transfer. The patient's height was 190.5 cm and weight was 59.3 kg (body surface area 1.83 m2). His preliminary diagnosis was chest pain with myocardial infarction as evidenced by elevated blood cardiac isoenzymes. His principle diagnosis was subendocardial infarction with paroxysmal ventricular tachycardia. Cardiac catheterization was performed and demonstrated severe triple vessel disease with an ejection fraction of 30%. He was evaluated and accepted as a candidate for coronary artery bypass grafting. Multidisciplinary consultation concluded that a safe and effective method of perioperative treatment would involve the use of arrested heart support with cold blood cardioplegia using a low prime miniature perfusion circuit as no blood products would be considered for use. Additionally, the combined modalities of perfusion interventions to minimize hemodilution consisted of intraoperative autologous blood collection totaling 500 mL and rapid autologous priming of the miniature perfusion circuit. The miniature perfusion system was a low prime Cardiovention (Santa Clara, CA) CORx device which includes a hollow-fiber oxygenator and integral centrifugal pump with a surface area of 1.2 m2. This system also incorporates an air sensing solenoid which triggers rapid air evacuation in a bolus range of 1 mL or greater. Kinetic venous drainage is another feature of this device as the centrifugal pump is integrated into the oxygenator. We believed that a miniature extracorporeal circuit would enhance the desired clinical outcome as opposed to the risk of: (1) off-pump coronary artery bypass (OPCAB) approach and the concern of emergent transition to an on-pump procedure and (2) use of larger surface area with conventional systems that impose a greater hemodilutional effect. Leukocyte filtration was employed as the patient had a significant past medical history of chronic obstructive pulmonary disease. We herein report our clinical experience with this method of treatment on a patient who refused the use of blood products in his surgical treatment. It is our belief that the multiple modalities utilized in combination during this procedure resulted in positive clinical outcomes as demonstrated by an intubation time of 8 hours 35 min with a discharge on the fifth postoperative day.

Obstetric hemorrhage is among the leading causes and the most preventable cause, of maternal mortality. Hemorrhage can be divided into early (stage 1) to late stages (stage 3), depending on the amount of blood lost and vital sign changes. Etiologies include antepartum hemorrhage such as abnormal placentation and postpartum hemorrhage such as uterine atony and retained products of conception. Early recognition of ongoing hemorrhage based on risk factors, vital sign changes, and quantification of blood loss is essential to adequately resuscitate the patient. Obstetric hemorrhage emergency flowcharts and the use of point-of-care testing such as rotational thromboelastometry have been developed to guide clinicians in their resuscitative efforts and blood product use as hemorrhage progresses. This review contains 5 figures, 6 tables and 29 references Key Words: abnormal placentation, antepartum hemorrhage, blood products, massive hemorrhage, maternal early warning signs of hemorrhage, postpartum hemorrhage, rotational thromboelastometry, uterine atony

ABSTRACTIn this study, the construct and the role of distributed situation awareness (DSA) on the anaesthetic management of challenging major obstetric haemorrhage (MOH) cases is explored, specifically the anaesthetist's perception of the operating theatre elements, the understanding of their meaning and the anticipation of their progress in interaction with other people and artefacts. Eighteen anaesthetists from four Scottish Hospitals were asked to discuss a challenging MOH case from their experience, prompted by questions emanating from a critical decision method protocol. The majority of the described DSA references were attributed to gathering information and in interaction with external artefacts, including monitors, suction containers, the whiteboard and even swabs. For understanding and anticipating, the majority of DSA references emerged in interaction with other team members within and outside the operating theatre. Methods for improving practice and training in MOH should address the interactive nature of DSA, by going beyond monitoring anaesthetic displays.