CG02N Analyzer Accurately Measures Fibrinogen Level in Whole Blood in the Presence of Low- or High-Dose Heparin

Rapid fibrinogen (Fbg) evaluation is important in patients with massive bleeding during severe trauma and those undergoing major surgery. However, there are only a few studies on the point-of-care Fbg analyzer. In this study, we aimed to investigate the accuracy of Fbg level measured using CG02N, with whole blood contained in lithium-heparinized syringes with two different concentrations of heparin. Blood samples were collected in lithium-heparinized tubes, namely PREZA-PAK®II (low-dose heparin group [LG], 7 IU/mL) and Pro-Vent® Plus (high-dose heparin group [HG], 70.5 IU/mL). The Fbg levels in LG and HG were compared with those of citrated plasma Fbg (standard-Fbg). Strong correlations with respect to the Fbg level were observed between standard-Fbg and LG or HG (r = 0.968, p < 0.0001; r = 0.970, p < 0.0001, respectively). We demonstrated that the Fbg level in whole-blood samples was accurately assessed by CG02N and not affected by low- or high-dose heparin.

Generating Rare Surgical Events Using CycleGAN: Addressing Lack of Data for Artificial Intelligence Event Recognition

INTRODUCTION

Artificial Intelligence (AI) has shown promise in facilitating surgical video review through automatic recognition of surgical activities/events. There are few public video data sources that demonstrate critical yet rare events which are insufficient to train AI for reliable video event recognition. We suggest that a generative AI algorithm can create artificial massive bleeding images for minimally invasive lobectomy that can be used to augment the current lack of data in this field.

MATERIALS AND METHODS

A generative adversarial network (GAN) algorithm was used (CycleGAN) to generate artificial massive bleeding event images. To train CycleGAN, six videos of minimally invasive lobectomies were utilized from which 1819 frames of nonbleeding instances and 3178 frames of massive bleeding instances were used.

RESULTS

The performance of the CycleGAN algorithm was tested on a new video that was not used during the training process. The trained CycleGAN was able to alter the laparoscopic lobectomy images according to their corresponding massive bleeding images, where the contents of the original images were preserved (e.g., location of tools in the scene) and the style of each image is changed to massive bleeding (i.e., blood automatically added to appropriate locations on the images).

CONCLUSIONS

The result could suggest a promising approach to supplement the lack of data for the rare massive bleeding event that can occur during minimally invasive lobectomy. Future work could be dedicated to developing AI algorithms to identify surgical strategies and actions that potentially lead to massive bleeding and warn surgeons prior to this event occurrence.

Exaggerated Placental Site as a Cause of Hysterectomy for Massive Bleeding After First Trimester Voluntary Abortion

Objectives

Placental implantation anomalies in first-trimester abortions may determine severe bleeding leading to hysterectomy. There are very few cases of urgent hysterectomy post-abortion reported in the literature, related to placenta accreta spectrum, but in any of them is considered association with benign trophoblastic lesions.

Methods

We report the case of a woman, who underwent surgical voluntary abortion by vacuum aspiration during first trimester, without any apparent surgical complications. Immediately, after this procedure, the patient had massive vaginal bleeding; an emergency hysterectomy was performed. Histological examination showed an exaggerated placental site (EPS).

Results

Morphological findings describe a trophoblastic tumor-like lesion, which differs from placenta accreta and often considered an asymptomatic occasional feature. Proliferative index, evaluated by double immunostain for CK8-18 and Ki-67, was unremarkable (<1%).

Conclusions

Only a single report in the literature describes a case of symptomatic EPS 65 after first-trimester abortion. Major attention should be paid to trophoblastic pathology in order to understand a possible relationship with uterine bleeding and to find a clinical, ultrasound or chemical indicator.

Trajectory of SARS-CoV-2 anti-S IgG levels following transfusion and a third dose of BNT162b2 vaccine in a patient with massive postoperative bleeding: A case report

Objective

Vaccination against SARS-CoV-2 has been shown to be effective in preventing infection and severe disease. Massive bleeding and transfusion after vaccination can lead to a decrease in the antibody level. The effect of an additional dose of vaccine after blood transfusion has not been described previously. In this case report, we report the SARS-CoV-2 anti-S IgG trajectory in a male patient who received a third dose of vaccine after a massive postoperative bleed and blood and plasma transfusion.

Case presentation

A 57-year-old male physician had a SARS-CoV-2 anti-S IgG level of 44 AU/mL, measured using the Lumipulse Presto chemiluminescence assay 3 months after receiving 2 doses of the BNT162b2 vaccine. The patient underwent a hemicolectomy for colon cancer, experienced massive postoperative bleeding, and required a transfusion. The patient's SARS-CoV-2 anti-S IgG level dropped to 9.2 AU/mL. A third dose of BNT162b2 vaccination was administered to reduce the risk of breakthrough infection. Fifteen days after receiving the third vaccine dose, the patient's SARS-CoV-2 anti-S IgG level increased to 421 AU/mL, likely to reflect protection.

Conclusion

This report suggests that administering an extra dose of vaccine is useful for restoring protective antibody levels in vaccinated patients who experience massive postoperative bleeding.

Gestational hemostasis: a natural model for hemostasis resuscitation of major periprocedural blood loss : "Look deep into nature, and then you will understand everything better." Albert Einstein

Early goal-directed treatment is an evidence-based approach to guide hemostatic therapy during major periprocedural bleeding. If viscoelastic coagulation tests are not available, an algorithm, termed the pyramid of hemostatic interventions, can help manage severe bleeding. Pregnant women accumulate huge reserves of prothrombotic and antifibrinolytic hemostatic elements to avoid peripartum blood loss. We provide comparison of therapeutic hemostatic approaches and natural gestational process and identified remarkable analogy between early goal-directed management of bleeding and hemostatic adaptation of pregnant woman. Therefore, gestational hemostasis serves as a natural model for goal-directed hemostasis resuscitation and can foster understanding of hemostatic management of periprocedural bleeding.

Splenic peliosis associated with spontaneous rupture and massive bleeding

We report findings from an autopsy case who died from massive bleeding because of splenic peliosis. The case subject was an 80-year-old man who had diabetes mellitus and who was receiving hemodialysis and anticoagulant therapy. Postmortem computed tomography demonstrated massive intra-abdominal hemorrhage especially seen around the spleen. At autopsy, we found abundant hemorrhagic ascites, including a large number of clots, in the abdominal cavity. The spleen had several distinct dark red areas ranging in size from 1.5 to 2.5 cm and showed spontaneous rupture along with hematoma formation on the outside of the splenic capsule on the anterior side. From these findings, we concluded that the cause of death in this case was massive hemorrhage owing to spontaneous rupture of splenic peliosis. Although peliosis itself rarely causes death, but when it is destroyed, massive bleeding leads to death. Thus, it is necessary to know the histopathological characteristics of peliosis, in forensics.

Normalization of blood clotting characteristics using prothrombin complex concentrate, fibrinogen and FXIII in an albumin based fluid: experimental studies in thromboelastometry

BACKGROUND

Colloid fluids supplemented with adequate combinations of coagulation factor concentrates with the capability to restore coagulation could be a desirable future treatment component in massive transfusion.

METHODS

Starting from a coagulation factor and blood cell-free albumin solution we added Prothrombin Complex Concentrate, Fibrinogen Concentrate and Factor XIII in different combinations and concentrations to analyze their properties to restore thromboelastometry parameters without the use of plasma. Further analysis under the presence of platelets was performed for comparability to whole blood conditions.

RESULTS

Albumin solutions enriched with Fibrinogen Concentrate, Factor XIII and Prothrombin Complex Concentrate at optimized concentrations show restoring coagulation potential. Prothrombin Complex Concentrate showed sufficient thrombin formation for inducing fibrinogen polymerization. The combination of Prothrombin Complex Concentrate and Fibrinogen Concentrate led to the formation of a stable in vitro fibrin clot. Fibrinogen and Factor XIII showed excellent capacity to improve fibrin clot firmness expressed as Amplitude at 10 min and Maximal Clot Firmness. Fibrinogen alone, or in combination with Factor XIII, was able to restore normal Amplitude at 10 min and Maximal Clot Firmness values. In the presence of platelets, the thromboelastometry surrogate parameter for thrombin generation (Clotting Time) improves and normalizes when compared to whole blood.

CONCLUSIONS

Combinations of coagulation factor concentrates suspended in albumin solutions can restore thromboelastometry parameters in the absence of plasma. This kind of artificial colloid fluids with coagulation-restoring characteristics might offer new treatment alternatives for massive transfusion.

TRIAL REGISTRATION

Study registered at the institutional ethic committee "Institut de Recerca, Hospital Santa Creu i Sant Pau, with protocol number IIBSP-CFC-2013-165.

Evaluation of hemostatic abnormalities in patients who underwent major hepatobiliary pancreatic surgery using activated partial thromboplastin time-clot waveform analysis

INTRODUCTION

Bleeding after major hepatobiliary pancreatic (HBP) surgery may be serious. Although postoperative abnormality of the hemostatic system are important elements that affect bleeding, routine activated partial thromboplastin time (APTT) assessment is considered inadequate to predict massive bleeding (MB). Recently, APTT-clot waveform analysis (CWA) was reported to be useful for detecting coagulation disorders.

METHODS

APTT-CWA was performed using the ACL-TOP analyzer in 188 patients who underwent four major HBP surgeries (distal pancreatectomy, hepatectomy, subtotal stomach-preserving pancreatoduodenectomy (SSPPD), and SSPPD with combined resection and reconstruction of the portal vein) to analyze its usefulness in predicting the risk of bleeding.

RESULTS

Seventy (37.2%) patients developed MB and the incidence of MB was highest among patients who underwent hepatectomy. There were no significant differences in routine APTT, the first derivative peak (DP) time and 1/2 fibrin formation peak time between patients with MB and those without MB, throughout the postoperative course. On the other hand, the first and second DP heights were significantly lower in patients with MB than in those without MB and lowest in patients who underwent hepatectomy.

CONCLUSION

APTT-CWA was able to detect the detailed changes in the hemostatic system after major HBP surgery. The patterns of APTT-CWA after major HBP surgery differed among various surgical procedures according to invasiveness. The lower first and the second DP height, which were frequently observed in hepatectomy patients, may be useful for predicting the risk of MB.

Anesthetic management of a patient with musculocontractural Ehlers-Danlos syndrome undergoing scoliosis surgery

Background

Musculocontractural Ehlers-Danlos syndrome is a new and rare subtype of Ehlers-Danlos syndrome in which anesthetic considerations for airway and respiratory management, prevention of skin injuries and joint dislocations, and hemostatic management for severe perioperative bleeding are required.

Case presentation

A 19-year-old woman with musculocontractural Ehlers-Danlos syndrome was scheduled to undergo posterior spinal fusion from the 4th thoracic to the 4th lumbar vertebrae under general anesthesia. Her trachea was easily intubated with a videolaryngoscope despite a small mouth and micrognathia. Pressure-controlled ventilation with limited peak inspiratory pressure was performed for prevention of pneumothorax. Skin damage and joint luxation were prevented by using a low rebounding mattress, terpolymer-based barrier film, and careful patient positioning. Blood transfusion was effectively performed on the basis of point-of-care viscoelastic hemostatic assay monitoring. She had an uneventful postoperative course without any complications.

Conclusions

We safely managed a patient with musculocontractural Ehlers-Danlos syndrome undergoing scoliosis surgery.

Prediction of massive transfusion in trauma patients in the surgical intensive care units (THAI-SICU study)

PURPOSE

After damage control surgery, trauma patients are transferred to intensive care units to restore the physiology. During this period, massive transfusion might be required for ongoing bleeding and coagulopathy. This research aimed to identify predictors of massive blood transfusion in the surgical intensive care units (SICUs).

METHODS

This is an analysis of the THAI-SICU study which was a prospective cohort that was done in the 9-university-based SICUs in Thailand. The study included only patients admitted due to trauma mechanisms. Massive transfusion was defined as received ≥10 units of packed red blood cells on the first day of admission. Patient characteristics and physiologic data were analyzed to identify the potential factors. A multivariable regression was then performed to identify the significant model.

RESULTS

Three hundred and seventy patients were enrolled. Sixteen patients (5%) received massive transfusion in the SICUs. The factors that significantly predicted massive transfusion were an initial sequential organ failure assessment (SOFA) ≥9 (risk difference (RD) 0.13, 95% confidence interval (CI): 0.03-0.22, p = 0.01); intra-operative blood loss ≥ 4900 mL (RD 0.33, 95% CI: 0.04-0.62, p = 0.02) and intra-operative blood transfusion ≥ 10 units (RD 0.45, 95% CI: 0.06 to 0.84, p = 0.02). The probability to have massive transfusion was 0.976 in patients who had these 3 factors.

CONCLUSION

Massive blood transfusion in the SICUs occurred in 5%. An initial SOFA ≥9, intra-operative blood loss ≥4900 mL, and intra-operative blood transfusion ≥10 units were the significant factors to predict massive transfusion in the SICUs.

The Dead Sea needs salt water… massively bleeding patients need whole blood: The evolution of blood product resuscitation

Whole blood, that is blood that is not manufactured into its component red blood cells (RBC) plasma, and platelets (PLT) units, was the mainstay of transfusion for many years until it was discovered that the component parts of a blood donation could be stored under different conditions thereby optimizing the storage length of each product. The use of low anti-A and -B titer group O whole blood (LTOWB) has recently been rediscovered for use in massively bleeding trauma patients. Whole blood has several advantages over conventional component therapy for these patients, including simplifying the logistics of the resuscitation, being more concentrated than whole blood that is reconstituted from conventional components, and providing cold-stored PLTs, amongst other benefits. While randomized controlled trials to determine the efficacy of using LTOWB in the resuscitation of massively bleeding trauma patients are currently underway, retrospective data has shown that massively bleeding recipients of LTOWB with traumatic injury do not have worse outcomes compared to patients who received conventional components and, in some cases, recipients of LTOWB have more favourable outcomes. This paper will describe some of the advantages of using LTOWB and will discuss the emerging evidence for its use in massively bleeding patients.

Prediction of massive bleeding in a prehospital setting: validation of six scoring systems

OBJECTIVE

To validate the diagnostic ability of six different scores to predict massive bleeding in a prehospital setting.

DESIGN

Retrospective cohort.

SETTING

Prehospital attention of patients with severe trauma.

SUBJECTS

Subjects with more than 15 years, a history of severe trauma (defined by code 15 criteria), that were initially assisted in a prehospital setting by the emergency services between January 2010 and December 2015 and were then transferred to a level one trauma center in Madrid.

VARIABLES

To validate: 1. Trauma Associated Severe Haemorrhage Score. 2. Assessment of Blood Consumption Score. 3. Emergency Transfusión Score. 4. Índice de Shock. 5. Prince of Wales Hospital/Rainer Score. 6. Larson Score.

RESULTS

548 subjects were studied, 76,8% (420) were male, median age was 38 (interquartile range [IQR]: 27-50). Injury Severity Score was 18 (IQR: 9-29). Blunt trauma represented 82,5% (452) of the cases. Overall, frequency of MB was 9,2% (48), median intensive care unit admission days was 2,1 (IQR: 0,8 - 6,2) and hospital mortality rate was 11,2% (59). Emergency Transfusión Score had the highest precisions (AUC 0,85), followed by Trauma Associated Severe Haemorrhage score and Prince of Wales Hospital/Rainer Score (AUC 0,82); Assessment of Blood Consumption Score was the less precise (AUC 0,68).

CONCLUSION

In the prehospital setting the application of any the six scoring systems predicts the presence of massive hemorrhage and allows the activation of massive transfusion protocols while the patient is transferred to a hospital.

Clinical Audit of Dengue Related Deaths in 2011-Mayo Hospital Lahore Pakistan

Background and Objective:

Dengue infection has evolved into an epidemic during last few years in Pakistan and has been associated with poor outcomes. Literature with respect to mortality risk factors in Dengue infection is not sufficient. This compelled us to conduct this study to find out major contributory factors to death in patients with dengue viral infection at one of Asia’s ancient hospital setting with an aim to recognize complications at earliest and improve case management in future.

Methods:

A retrospective observational study of 95 adult dengue deaths was performed at Mayo Hospital Lahore from July 1st 2011 to 31st December 2011 during a major dengue epidemic. Patients who tested positive by dengue IgM in the presence of acute fever fulfilling the World Health Organization criteria for Dengue Fever, Dengue Hemorrhagic Fever or Dengue Shock Syndrome and died within same setting, were included. Data regarding demographic profile, clinical and laboratory parameters along with treatment details were obtained and analysed. All records examined were anonymized.

Results:

Median age was 36 years (range13-80 years) among 95 deaths due to Dengue. Male gender comprised 60 (63.1%). Co-morbidities existed in 74 (77.9%) with hypertension in 21 (22.1%) diabetes in 11 (11.58%), liver disease in 9 (9.47%) and ischemic heart disease in 8(8.4%) cases. Patients presented at second day of fever for admission (range 1-8 days) and death occurred at a median of 4 days (range 30 minutes to 23 days). Hospital stay was for less than a week for seventy nine (83.2%) patients and 16 (16.8%) were admitted for more than 7 days. Critical care was required in 67(71%). Severe hepatitis occurred in 41 (43.1%), acute renal impairment occurred in 32 (33.7%) and disseminated intravascular coagulation in 16 (16.8%). Deaths were due to prolonged shock 49 (51.5%) fluid overload 46 (48.4%) and massive bleeding 18(19%) leading to organ failure.

Conclusion:

Decompensated shock complicated by either massive plasma leakage, frank bleeding, multi organ failure or deranged clotting profile results in enhanced mortality in Dengue infection. Co-morbidities especially Diabetes are poor prognostic factors in predicting Dengue mortality.

Automatic detection of surgical haemorrhage using computer vision

BACKGROUND AND OBJECTIVES

On occasions, a surgical intervention can be associated with serious, potentially life-threatening complications. One of these complications is a haemorrhage during the operation, an unsolved issue that could delay the intervention or even cause the patient's death. On laparoscopic surgery this complication is even more dangerous, due to the limited vision and mobility imposed by the minimally invasive techniques.

METHODS

In this paper it is described a computer vision algorithm designed to analyse the images captured by a laparoscopic camera, classifying the pixels of each frame in blood pixels and background pixels and finally detecting a massive haemorrhage. The pixel classification is carried out by comparing the parameter B/R and G/R of the RGB space colour of each pixel with a threshold obtained using the global average of the whole frame of these parameters. The detection of and starting haemorrhage is achieved by analysing the variation of the previous parameters and the amount of pixel blood classified.

RESULTS

When classifying in vitro images, the proposed algorithm obtains accuracy over 96%, but during the analysis of an in vivo images obtained from real operations, the results worsen slightly due to poor illumination, visual interferences or sudden moves of the camera, obtaining accuracy over 88%. The detection of haemorrhages directly depends of the correct classification of blood pixels, so the analysis achieves an accuracy of 78%.

CONCLUSIONS

The proposed algorithm turns out to be a good starting point for an automatic detection of blood and bleeding in the surgical environment which can be applied to enhance the surgeon vision, for example showing the last frame previous to a massive haemorrhage where the incision could be seen using augmented reality capabilities.

Pathophysiology of trauma-induced coagulopathy: disseminated intravascular coagulation with the fibrinolytic phenotype

In severe trauma patients, coagulopathy is frequently observed in the acute phase of trauma. Trauma-induced coagulopathy is coagulopathy caused by the trauma itself. The pathophysiology of trauma-induced coagulopathy consists of coagulation activation, hyperfibrino(geno)lysis, and consumption coagulopathy. These pathophysiological mechanisms are the characteristics to DIC with the fibrinolytic phenotype.

Culprit for recurrent acute gastrointestinal massive bleeding: “Small bowel Dieulafoy’s lesions” - a case report and literature review

A Dieulafoy's lesion is a dilated, aberrant, submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. It can be located anywhere in the gastrointestinal tract. We describe a case of massive gastrointestinal bleeding from Dieulafoy’s lesions in the duodenum. Etiology and precipitating events of a Dieulafoy’s lesion are not well known. Bleeding can range from being self-limited to massive life- threatening. Endoscopic hemostasis can be achieved with a combination of therapeutic modalities. The endoscopic management includes sclerosant injection, heater probe, laser therapy, electrocautery, cyanoacrylate glue, banding, and clipping. Endoscopic tattooing can be helpful to locate the lesion for further endoscopic re-treatment or intraoperative wedge resection. Therapeutic options for re-bleeding lesions comprise of repeated endoscopic hemostasis, angiographic embolization or surgical wedge resection of the lesions. We present a 63-year-old Caucasian male with active bleeding from the two small bowel Dieulafoy’s lesions, which was successfully controlled with epinephrine injection and clip applications.

Definitions, predictors and challenges

BACKGROUND

Severe or massive bleeding in cardiac surgery is an uncommon but important clinical scenario. Its existing definitions are diverse. Its characteristics constantly change during an active hemorrhage and, thus is difficult to define appropriately.

METHODS

In this narrative, non-systematic review, we performed a literature search to retrieve data that could contribute to answering clinical questions on the definition and grading of severe hemorrhage and massive transfusion, identifying factors that predict and affect bleeding and transfusion-related mortality and describing the risks of re-exploration and the economic impact of severe bleeding in cardiac surgery.   Results: Massive perioperative bleeding is currently described by indices of its rate and extent and the magnitude of the consequent blood products transfusion. It has a significant impact on mortality, service logistics, and hospital financing. Proper and early identification of a massive bleeding is possible. Among other factors, patient's co-morbidities, bleeding severity and transfusion volume seem to predict the associated mortality. Consequent to severe bleeding, re-exploration, is also a potentially hazardous adverse event that also affects morbidity and mortality.

CONCLUSIONS

Severe perioperative hemorrhage in cardiac surgery carries significant morbidity and mortality. Currently, prediction and identification of massive bleeding is a feasible but incomplete clinical task despite the availability of effective treatment regimens. A still missing, compact definition of massive perioperative bleeding in cardiac surgery that incorporates all phases of treatment could augment clinical preparedness, allow for the development of accurate prediction tools and permit the application of well-validated protocols of management. Hippokratia 2016, 20(3): 179-186.

Use of tranexamic acid in combat casualties. Experience of the Spanish medical corps. Clinical series and literature review

OBJECTIVE

To describe the experience with tranexamic acid (TXA) during the care of combat causalities treated in the Spanish military hospital based in Herat (Afghanistan) and to perform an analysis of the literature related to the military setting.

MATERIAL AND METHODS

With the approval of the appropriate military institutions, an analysis was performed on the use of TXA in combat casualties treated between March and May 2014. Of the 745 patients seen, 10 were due to a firearm/explosive device (combat casualties). A descriptive analysis was performed on the data collected. Absolute and relative frequencies (%) were used for the categorical variables. For central tendency measurements, the arithmetic mean and standard deviation or the median and interquartile range was calculated. The data were obtained from the military records of patients treated in the Herat military hospital.

RESULTS

All the patients in this series received TXA within the first 3 hours after the attack. The most frequent dose used was one gram i.v, with bleeding was controlled in 100% of cases. All the patients survived and none of them had secondary effects. These data agree with that recommended in the combat casualties treatment guide followed by military health in other countries in this setting.

CONCLUSION

All combat casualties were treated with TXA within the first 3 hours. The most frequent dose used was one gram iv and bleeding was controlled in all cases. All the patients survived with no adverse effects being observed.

Protocols for massive blood transfusion: when and why, and potential complications

PURPOSE

An update paper on massive bleeding after major trauma. A review of protocols to address massive bleeding, and its possible complications, including coagulation abnormalities, complications related to blood storage, immunosuppression and infection, lung injury associated with transfusion, and hypothermia is carried out.

METHODS

Literature review and discussion with authors' experience.

RESULTS

Massive bleeding is an acute life-threatening complication of major trauma, and consequently its prompt diagnosis and treatment is of overwhelming importance. Treatment requires rapid surgical management together with the massive infusion of colloid and blood.

CONCLUSIONS

Since massive transfusion provokes further problems in patients who are already severely traumatized and anaemic, once this course of action has been decided upon, a profound knowledge of its potential complications, careful monitoring and proper follow-up are all essential. To diagnose this bleeding, most authors favour, as the main first choice tool, a full-body CT scan (head to pelvis), in non-critical severe trauma cases. In addition, focused abdominal sonography for trauma (FAST, an acronym that highlights the necessity of rapid performance) is a very important diagnostic test for abdominal and thoracic bleeding. Furthermore, urgent surgical intervention should be undertaken for patients with significant free intraabdominal fluid and haemodynamic instability. Although the clinical situation and the blood haemoglobin concentration are the key factors considered in this rapid decision-making context, laboratory markers should not be based on a single haematocrit value, as its sensitivity to significant bleeding may be very low. Serum lactate and base deficit are very sensitive markers for detecting and monitoring the extent of bleeding and shock, in conjunction with repeated combined measurements of prothrombin time, activated partial thromboplastin time, fibrinogen and platelets.

Arterial hemorrhage from cesarean scar: a rare cause of recurring massive uterine bleeding and successful surgical management

Abnormal uterine bleeding and other gynecologic complications associated with a previous cesarean section scar are only recently being identified and described. Herein we report a rare case of a woman with recurring massive uterine bleeding after 2 cesarean sections. Curettage and hormone therapy were unsuccessfully used in an attempt to control the bleeding. After she was transferred to our hospital, she had another episode of vaginal bleeding that was successfully managed with oxytocin and hemostatic. Diagnostic hysteroscopy performed under anesthesia revealed an abnormal transected artery in the cesarean section scar with a thrombus visible. In the treatment at the beginning of laparoscopic management, we adopted temporary bilateral uterine artery occlusion with titanium clips to prevent massive hemorrhage. Secondly, with the aid of hysteroscopy, the bleeding site was opened, and then the cesarean scar was wedge resected and stitched interruptedly with 1-0 absorbable sutures. The postoperative recovery was uneventful. It would seem that the worldwide use of cesarean section delivery may contribute to the risk of gynecologic disturbances including some unrecognized and complex conditions as seen in this case.

Rectal ulcers and massive bleeding after hemorrhoidal band ligation while on aspirin

Endoscopic hemorrhoidal band ligation is a well-established nonoperative method for treatment of bleeding internal hemorrhoids (grade 1 to 3). It is a safe and effective technique with a high success rate. Complications with this procedure are uncommon. Although rectal ulceration due to band ligation is a rare complication, it can cause life-threatening hemorrhage especially when patients are on medications which impair hemostasis like aspirin or non steroidal anti-inflammatory drugs. We present 2 cases of massive lower gastro-intestinal bleeding in patients who had a band ligation procedure performed 2 wk prior to the presentation and were on aspirin at home. Both the patients were hemodynamically unstable requiring resuscitation. They required platelet and blood transfusions and were found to have rectal ulcers on colonoscopy done subsequently. The rectal ulcers corresponded to the site of band ligation. The use of aspirin by these patients would have caused defects in the hemostasis and may have predisposed them to massive bleeding in the presence of rectal ulcers occurring after the band ligation procedure. Managing aspirin before and after the ligation may be difficult especially since adequate guidelines are unavailable. Stopping aspirin in all the cases might not be safe and the decision should be individualized.

Black esophagus (acute esophageal necrosis) after spinal anesthesia

Acute esophagic necrosis or black esophagus is an uncommon clinical entity that owes its name to the endoscopic view of the necrotic esophageal mucosa. It is always related with a critical medical condition and usually has an ischemic etiology. We report the first case of acute esophageal necrosis after a spinal anesthetic for partial hip joint arthroplasty. We discuss the underlying pathophysiological mechanisms.

Angiographic embolization in the treatment of arterial pelvic hemorrhage: evaluation of prognostic mortality-related factors

Purpose

The control of arterial bleeding associated with pelvic ring and acetabular fractures (PRAF) remains a challenge for emergency trauma care. The aim of the present study was to uncover early prognostic mortality-related factors in PRAF-related arterial bleedings treated with transcatheter angiographic embolization (TAE).

Methods

Forty-nine PRAF patients (46 pelvic ring and three acetabular fractures) with arterial pelvic bleeding controlled with TAE (within 24 h) were evaluated.

Results

All large arterial disruptions (n = 7) were seen in type C pelvic ring injuries. The 30-day mortality in large vessel (iliac artery) bleeding was higher (57 %) than in medium- or small-size artery bleeding (24 %). Overall 30-day mortality was 29 %. No statistically significant difference in the first laboratory values between the survivors and nonsurvivors was found. However, after excluding patients dying of head injuries (n = 5), a reasonable cut-off value was identified for the base excess (BE; lower than −10 mmol/l) obtained on admission.

Conclusions

PRAF patients with exsanguinating bleeding from the large pelvic artery have the worst prognosis. Very low BE values (<−10.0 mmol/l) on admission for exsanguinating patients have a negative predictive value for survival, thus anticipating a poor outcome in bleeding controlled with TAE only and an increased risk of death. In critical cases, an aggressive bleeding control protocol prompts extraperitoneal pelvic packing prior to TAE. PRAF-related rupture of the external iliac artery is rare and indicates surgical techniques in controlling and restoring blood supply to the lower leg.

Emergency transcatheter arterial embolization for patients with acute massive duodenal ulcer hemorrhage

AIM: To evaluate the efficacy and safety of emergency transcatheter arterial embolization (ETAE) for patients with acute massive duodenal ulcer hemorrhage.

METHODS: Twenty-nine consecutive patients with acute massive bleeding of duodenal ulcer were admitted to our hospital from 2006 to 2011. Superselective angiography of the celiac and gastroduodenal arteries was performed to find out the bleeding sites before ETAE, then, embolotherapy was done with gelatin sponge particles or microstrips via a 5 French angiographic catheter or 3 French microcatheter. After ETAE, further superior mesenteric arteriography was undertaken in case collateral circulation supplied areas of the duodenal ulcer. Technical and clinical success rates were analyzed. Changes in the mucous membrane were observed using endoscopy following ETAE.

RESULTS: Angiography showed active bleeding with extravasation of contrast medium in seven cases with a 24% positive rate of celiac artery bleeding, and in 19 cases with a 65.5% rate of gastroduodenal artery bleeding. There were no angiographic signs of bleeding in three patients who underwent endoscopy prior to ETAE. Twenty-six patients achieved immediate hemostasis and technical success rate reached 90%. No hemostasis was observed in 27 patients within 30 d after ETAE and clinical success rate was 93%. Recurrent hemorrhage occurred in two patients who drank a lot of wine who were treated by a second embolotherapy in the same way. Five patients underwent transient ischem with light abdominal pain under xiphoid, spontaneous restoration without special treatment. No mucous necrosis happened to 29 cases for ischem of gastroduodenal arteries embolized.

CONCLUSION: ETAE is an effective and safe measure to control acute massive bleeding of duodenal ulcer.

Severe pelvic fracture-related bleeding in pediatric patients: does it occur?

PURPOSE

Pediatric pelvic fractures are rare and less likely to cause hemodynamic instability than similar injuries in adult patients. The associated injuries are common, and they have a major impact on mortality. The aim of the present study was to evaluate the risk of life-threatening hemorrhage associated with unstable pelvic fractures in children.

METHODS

We identified retrospectively all pediatric pelvic fractures (ring and acetabulum) treated at Helsinki University Central Hospital during a 10-year period (1998-2007). Stable A-type fractures (fractures not involving the pelvic ring) were excluded. All available pre- and in-hospital medical records were reviewed. The collected data consisted of patient characteristics, mechanisms of injury, vital signs, laboratory tests, care given, other injuries diagnosed, and the 30-day survival rate.

RESULTS

There were 71 (40 males) pediatric patients (median age 14, range 1-16 years) with unstable pelvic fractures; 66 pelvic ring and 5 acetabulum fractures. The most common mechanism of injury was traffic accident (69%). Four patients had life-threatening bleeding. All had fracture of a mature pelvic ring, but the source of massive bleeding was pelvic ring fracture in only two patients (2.8% of all patients). No acetabulum fracture-related major pelvic bleeding was observed. One patient (age 16 years) required emergency surgery and angioembolization for pelvic bleeding. No life-threatening pelvic bleeding was seen among patients with immature bony pelvis. Pelvic ring fractures were surgically treated in 25 patients. Two patients died from head injuries (overall mortality 2.8%), but there were no bleeding-related deaths.

CONCLUSIONS

We conclude that life-threatening bleeding from pelvic or acetabular fractures in pediatric patients is rare (2.8%), and does not contribute to the overall mortality.

Role of transcatheter arterial embolization for massive bleeding from gastroduodenal ulcers

Intractable bleeding from gastric and duodenal ulcers is associated with significant morbidity and mortality. Aggressive treatment with early endoscopic hemostasis is essential for a favourable outcome. In as many as 12%-17% of patients, endoscopy is either not available or unsuccessful. Endovascular therapy with selective catheterization of the culprit vessel and injection of embolic material has emerged as an alternative to emergent operative intervention in high-risk patients. There has not been a systematic literature review to assess the role for embolotherapy in the treatment of acute upper gastrointestinal bleeding from gastroduodenal ulcers after failed endoscopic hemostasis. Here, we present an overview of indications, techniques, and clinical outcomes after endovascular embolization of acute peptic-ulcer bleeding. Topics of particular relevance to technical and clinical success are also discussed. Our review shows that transcatheter arterial embolization is a safe alternative to surgery for massive gastroduodenal bleeding that is refractory to endoscopic treatment, can be performed with high technical and clinical success rates, and should be considered the salvage treatment of choice in patients at high surgical risk.

Single-center experience of 309 consecutive patients with obscure gastrointestinal bleeding

AIM: To investigate the diagnostic yield of capsule endoscopy (CE) in patients with obscure gastrointestinal bleeding (OGIB), and to determine whether the yield was affected by different bleeding status.

METHODS: Three hundred and nine consecutive patients (all with recent negative gastric and colonic endoscopy results) were investigated with CE; 49 cases with massive bleeding and 260 cases with chronic recurrent overt bleeding. Data regarding OGIB were obtained by retrospective chart review and review of an internal database of CE findings.

RESULTS: Visualization of the entire small intestine was achieved in 81.88% (253/309) of cases. Clinically positive findings occurred in 53.72% (166/309) of cases. The positivity of the massive bleeding group was slightly higher than that of the chronic recurrent overt bleeding group but there was no significant difference (59.18% vs 52.69%, P > 0.05) between the two groups. Small intestinal tumors were the most common finding in the entire cohort, these accounted for 30% of clinically significant lesions. In the chronic recurrent overt bleeding group angioectasia incidence reached more than 29%, while in the massive bleeding group, small intestinal tumors were the most common finding at an incidence of over 51%. Increasing patient age was associated with positive diagnostic yield of CE and the findings of OGIB were different according to age range. Four cases were compromised due to the capsule remaining in the stomach during the entire test, and another patient underwent emergency surgery for massive bleeding. Therefore, the complication rate was 1.3%.

CONCLUSION: In this study CE was proven to be a safe, comfortable, and effective procedure, with a high rate of accuracy for diagnosing OGIB.

Massive bleeding from a ruptured artery in jejunal diverticulosis without pre-existing mucosal inflammation or ulceration

A case of massive bleeding from a ruptured artery in jejunal diverticulosis without pre-existing mucosal inflammation or ulceration is presented. A 75-year-old bed-ridden man had massive gastrointestinal bleeding and deteriorated to a state of shock rapidly. Panendoscopy, selective abdominal angiography, and radionuclide scanning were performed, but none of these studies revealed the exact bleeding point. Emergent operation revealed a segment of jejunal diverticulosis with bleeding, and it was resected. Pathologic examination revealed tortuous veins in the submucosa of diverticula and a ruptured artery with evidence of active bleeding in a large diverticulum. No pre-existing mucosal inflammation or ulceration was seen. The bleeding cause is thought to be acquired false diverticular wall tearing of a submucosal artery by bowel distension or unknown moving content.

Transcatheter arterial embolization for patients with acute massive hemorrhage of duodenal ulcer: an analysis of 29 cases

AIM: To evaluate the efficacy and safety of emergency transcatheter arterial embolization (ETAE) for patients with acute massive hemorrhage of duodenal ulcer.

METHODS: Twenty-nine consecutive patients with acute massive bleeding of duodenal ulcer admitted to our hospital from 1997 through 2007 were analyzed. Superselective angiographies at celiac arteries, gastroduodenal arteries were performed to find out the bleeding sites before ETAE, then, embolotherapy was done with gelatin sponge particles or microstrips via 5French angiographic catheter or 3French microcatheter. After ETAE, another superior mesenteric arterioangiography was undertaken in case of collateral circulation supplied to areas of duodenal ulcer. Technique success rate and clinical success rate were analyzed. Changes of the mucous membrane, were observed using endoscopy following ETAE.

RESULTS: Angiographies showed active bleeding with extravasation of contrast medium in 7 cases with 24% positive rate of bleeding at celiac arteries, and in 19 cases, 65.5% at gastroduodenal arteries. No bleeding signs of angiography were shown in 3 cases who undertook endoscopy prior to ETAE. Twenty-six patients achieved immediate hemostasis and technique success rate reached 90%. No hemostasis was observed in 27 patients within 30 days after ETAE and clinical success rate was 93%. Recurrent hemorrhage occurred in 2 patients who drank wine a lot were treated by a second embolotherapy in the same way. Five patients underwent transient ischem with light abdominal pain under xiphoid, spontaneous restoration without special treatment. No mucous necrosis happened to 29 cases for ischem of gastroduodenal arteries embolized.

CONCLUSION: Tranascatheter arterial emoblization is an effective and safe measure to control acute massive bleeding of duodenial ulcer.