Hemostatic strategies for minimizing mortality in surgery with major blood loss:

Patient blood management in major digestive surgery: Recommendations from the Italian multisociety (ACOI, SIAARTI, SIdEM, and SIMTI) modified Delphi consensus conference

Patient blood management (PBM) is defined as the timely application of evidence-based medical and surgical concepts designed to maintain a surgical patient’s hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve the outcomes. PBM is able to reduce mortality up to 68%, reoperation up to 43%, readmission up to 43%, composite morbidity up to 41%, infection rate up to 80%, average length of stay by 16%–33%, transfusion from 10% to 95%, and costs from 10% to 84% after major surgery. It should be noticed, however, that the process of PBM implementation is still in its infancy, and that its potential to improve perioperative outcomes could be strictly linked to the degree of adherence/compliance to the whole program, with decoupling and noncompliance being significant factors for failure. Therefore, the steering committees of four major Italian scientific societies, representing general surgeons, anesthesiologists and transfusion medicine specialists (Associazione Chirurghi Ospedalieri Italiani; Società Italiana di Anestesia, Analgesia, Rianimazione e Terapia Intensiva; Società Italiana di Emaferesi e Manipolazione Cellulare; Società Italiana di Medicina Trasfusionale e Immunoematologia), organized a joint modified Delphi consensus conference on PBM in the field of major digestive surgery (upper and lower gastrointestinal tract, and hepato-biliopancreatic resections), whose results and recommendations are herein presented.

Iatrogenic aortic dissection after minimally invasive aortic valve replacement: a case report

BACKGROUND

As minimally invasive cardiac and vascular procedures are on the rise, the incidence of iatrogenic acute aortic dissection (IAAD) will increase. Cardiovascular professionals should be aware about the risk factors, means of prevention and best management options for IAAD in the perioperative setting.

CASE PRESENTATION

We present the successful clinical management of a complicated case of IAAD after minimally invasive aortic valve replacement.

CONCLUSION

High index of suspicion is required for prompt diagnosis of IAAD; collaboration of the whole perioperative team is imperative for management of this catastrophe.

Optimizing Transfusion Ratios in Massive Transfusion Protocols: An Argument Against the 1:1:1 Dogma and Approach to Trauma Resuscitation

We believe that the current practice of transfusing red blood cells (RBCs), plasma, and platelets in a 1:1:1 ratio is not optimal in massive transfusion protocols (MTPs) and is based on a simple yet profound misconception regarding the preparation of component blood products. This 1:1:1 approach ignores the additional fluids added for anticoagulation and preservation of the components and assumes that there is a one-size-fits-all ratio that must be used across all types of trauma. In this article, we explain the rationale behind our conclusion with supporting figures and suggest that although the 1:1:1 ratio might be within the range of hemostasis, it falls near the lower cusp of hemostasis, making it less than ideal. The patient in mind was one in whom transfusion was expected to exceed 10 units of packed RBCs (pRBCs) in a combat environment where the situation was too hectic for additional testing. The goal was to keep the patient within a hemostatic range until the crisis phase was averted and the transition could then be made to goal-directed therapy with point-of-care testing.

Viscoelastic guidance of resuscitation

PURPOSE OF REVIEW

Bleeding in trauma carries a high mortality and is increased in case of coagulopathy. Our understanding of hemostasis and coagulopathy has improved, leading to a change in the protocols for hemostatic monitoring. This review describes the current state of evidence supporting the use of viscoelastic hemostatic assays to guide trauma resuscitation.

RECENT FINDINGS

Viscoelastic hemostatic assays such as thrombelastography and rotational thrombelastometry have shown to reduce bleeding, transfusion of fresh frozen plasma and platelets, and possibly mortality in different surgical populations. In trauma care, viscoelastic hemostatic assays allows for rapid and timely identification of coagulopathy and individualized, goal-directed transfusion therapy. As part of the resuscitation concept, viscoelastic hemostatic assays seem to improve outcome also in trauma; however, there is a need for randomized clinical trials to confirm this.

SUMMARY

We are moving toward avoiding coagulopathy by individualized, goal-directed transfusion therapy, using viscoelastic hemostatic assays to guide ongoing resuscitation of actively bleeding patients in a goal-directed manner.

Hypercoagulation Assessed by Thromboelastography is Neither Related to Infarct Size nor to Clinical Outcome After Primary Percutaneous Coronary Intervention

Objectives:

We investigated the relationship between coagulation assessed by thromboelastography (TEG) and myocardial damage in ST-segment elevation myocardial infarction (STEMI).

Methods:

We measured platelet activity with TEG-maximum amplitude (TEG-MA) in 233 patients undergoing urgent percutaneous coronary intervention (PCI). Infarct size and myocardial salvage index were evaluated using cardiac magnetic resonance, and the relation of these parameters to posttreatment coagulation was examined retrospectively. Adverse events were adjudicated and related to the coagulation status during the index event.

Results:

Hypercoagulation was found in 82 (35.2%) patients and was neither correlated to infarct size nor correlated to myocardial salvage index ( P = .28 and .65, respectively) or clinical adverse events. Patients who experienced an adverse event during follow-up had a slightly higher TEG-MA value than patients with an event-free follow-up, but this was not statistically significant (68.1 vs 67.3, P = .44).

Conclusions:

The TEG-MA does not appear to be a sensitive predictor of reperfusion success and prognosis in urgent PCI for STEMI.

Massive transfusion protocols for patients with substantial hemorrhage

Transfusion medicine for the resuscitation of patients with massive hemorrhage has recently advanced from reactive, supportive treatment with crystalloid and red blood cell therapy to use of standardized massive transfusion protocols (MTPs). Through MTPs, medical facilities are able to standardize the most effective posthemorrhage treatments and execute them rapidly while reducing potential waste of blood products. Damage control resuscitation is an example of an MTP, where patients are (1) allowed more permissive hypotension, (2) spared large volumes of crystalloid/colloid therapy (through low volume resuscitation), and (3) transfused with blood products preemptively using a balanced ratio of plasma and platelets to red blood cells. This focused approach improves the timely availability of blood components during resuscitation. However, the use of MTPs remains controversial. This review describes published experiences with MTPs and illustrates the potential value of several MTPs currently utilized by academic transfusion services.