Appreciation of the large volume deficits which may occur in surgical or trauma patients due to blood loss has led to vigorous transfusion techniques designed to overt hypovolemic shock and ischemic damage to vital organs which may develop in minutes during the hypovolemic state. In a significant proportion of patients treated with massive rapid blood or fluid transfusion, hypervolemia occurs and life threatening pulmonary edema may develop. Especially, hypervolemia may occur during transfusion for preventing development of the so-called low output syndrome following cardiac surgery. However, the most effective indicator which reveals the adequate level of transfusion is not settled yet. The present study was aimed to compare the effectiveness of the indicators suggested thus far and to determine the most sensitive one. Eight dogs were experimentally studied in terms of left atrial pressure, pulmonary arterial systolic pressure, central venous pressure, mean systemic arterial pressure and heart rate before and after induced hypervolemia with infusion of 600ml heparinized homologous blood. Immediately after induced overtransfusion of the blood, pulmonary arterial systolic pressure increased 75.0%, in omparison with the control before transfusion, left atrial pressure 58.8%, central venous pressure 44.6%, and mean systemic arterial pressure 10.1%, one hour after transfusion, pulmonary arterial systolic pressure 40.0%, left atrial pressure 21.2%, central venous pressure 14.5%, and mean systemic arterial pressure 3.2%, central venous pressure 14.5%, and mean systemic arterial pressure 3.2%, respectively. Heart rate showed no significant change throughout the experiment. These result suggested that the changes of the pulmonary arterial systolic pressure is the most sensitive indicator for detection of hypervolemia during blood transfusion.
Background: Orthotopic organ transplantation, a treatment option for irreversible organ dysfunction according to organ failure, severe damaged organ or malignancy in situ, was usually accompanied with massive blood loss thus transfusion was required. We aimed to evaluate the adverse impact of blood transfusion on solid organ transplantation. Materials and Methods: From January, 2009 to December, 2014, patients who received orthotopic organ transplantation at Far Eastern Memorial Hospital medical center were enrolled. Clinical data regarding anemia status and red blood cell (RBC) transfusion before, during and after operation, as well as patient outcomes were collected for further univariate analysis. Results: A total of 105 patients who underwent orthotopic transplantation, including liver, kidney and small intestine were registered. The mean hemoglobin (Hb) level upon admission and before operation were $11.6{\pm}1.8g/dL$ and $11.7{\pm}1.7g/dL$, respectively; and the nadir Hb level post operation and the final Hb level before discharge were $8.3{\pm}1.6g/dL$ and $10.2{\pm}1.6g/dL$, respectively. The median units (interquartile range) of RBC transfusion in pre-operative, peri-operative and post-operative periods were 0 (0-0), 2 (0-12), and 2 (0-6) units, respectively. Furthermore, the median (interquartile range) length of hospital stay (LHS) from admission to discharge and from operation to discharge were 28 (17-44) and 24 (16-37) days, respectively. Both peri-operative and post-operative RBC transfusion were associated with longer LHS from admission to discharge and from operation to discharge. Furthermore, it increased the risk of post-operative septicemia. While peri-operative RBC transfusion elevated the risk of acute graft rejection in patients who received orthotopic transplantation. Conclusions: Worse outcome could be anticipated in those who had received massive RBC transfusion in transplantation operation. Hence, peri-operative RBC transfusion should be avoided as much as possible.
Lee, Sang Sik;Bae, Byung Kwan;Han, Sang Kyoon;Park, Sung Wook;Ryu, Ji Ho;Jeong, Jin Woo;Yeom, Seok Ran
Journal of Trauma and Injury
/
v.25
no.4
/
pp.139-144
/
2012
Purpose: Hypovolemic shock is the leading cause of death in multiple trauma patients with pelvic bone fracures. The purpose of this study was to develop a simple prediction method for injury severity and amount of hemorrhage via an analysis of the correlation between the site of pelvic bone fracture and the amount of transfusion and to verify the usefulness of the such a simple scoring system. Methods: We analyzed retrospectively the medical records and radiologic examination of 102 patients who had been diagnosed as having a pelvic bone fracture and who had visited the Emergency Department between January 2007 and December 2011. Fracture sites in the pelvis were confirmed and re-classified anatomically as pubis, ilium or sacrum. A multiple linear regression analysis was performed on the amount of transfusion, and a simplified scoring system was developed. The predictive value of the amount of transfusion for the scoring system as verified by using the receiver operating characteristics (ROC). The area under the curve of the ROC was compared with the injury severity score (ISS). Results: From among the 102 patients, 97 patients (M:F=68:29, mean $age=46.7{\pm}16.6years$) were enrolled for analysis. The average ISS of the patients was $16.2{\pm}7.9$, and the average amount of packed RBC transfusion for 24 hr was $3.9{\pm}4.6units$. The regression equation resulting from the multiple linear regression analysis was 'packed RBC units=1.40${\times}$(sacrum fracture)+1.72${\times}$(pubis fracture)+1.67${\times}$(ilium fracture)+0.36' and was found to be suitable (p=0.005). We simplified the regression equation to 'Pelvic Bleeding Score=sacrum+pubis+ilium.' Each fractured site was scored as 0(no fracture) point, 1(right or left) point, or 2(both) points. Sacrum had only 0 or 1 point. The score ranged from 0 to 5. The area under the curve (AUC) of the ROC was 0.718 (95% CI: 0.588-0.848, p=0.009). For an upper Pelvis Bleeding Score of 3 points, the sensitivity of the prediction for a massive transfusion was 71.4%, and the specificity was 69.9%. Conclusion: We developed a simplified scoring system for the anatomical fracture sites in the pelvis to predict the requirement for a transfusion (Pelvis Bleeding Score (PBS)). The PBS, compared with the ISS, is considered a useful predictor of the need for a transfusion during initial management.
Kim, Hyerin;Yoo, Dong-Won;Kim, Hyerim;Shin, Kyung-Hwa;Lee, Hyun-Ji;Chang, Chulhun L.;Kim, Hyung-Hoi
The Korean Journal of Blood Transfusion
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v.29
no.3
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pp.262-272
/
2018
Background: Massive hemorrhage due to trauma is one of the major causes of death in trauma patients, and the quick supply of appropriate blood products is critical in order to reduce the mortality rate. We introduced a massive transfusion protocol (MTP) for safe and rapid transfusion of trauma patients. Using records collected since its adoption, we compared the characteristics of MTP applied group (MTP group) and MTP not applied group (non-MTP group) to determine whether there is an indicator for predicting patients to be treated with MTP. Methods: We retrospectively reviewed the electronic medical records and laboratory findings of patients who received massive transfusions in the trauma emergency room of a single tertiary hospital from February to August 2018. We analyzed various laboratory test results, the amount and ratio of the transfused blood products, and the time required for blood products to be released for the MTP group and the non-MTP group. Results: Of the 54 trauma patients who received massive transfusions, 31 were in the MTP group and 22 in the non-MTP group. There was no significant difference in initial vital signs (except blood pressure) and laboratory test results. Also there was no difference in the amount and ratio of blood products, but the time required for blood product release was shorter in the MTP group. Conclusion: There was no significant difference in clinical findings such as initial vital signs and laboratory test results between the MTP and non-MTP groups, but required blood products were prepared and released more quickly for the MTP group.
Sun, Hyun Woo;Lee, Sang Bong;Park, Sung Jin;Park, Chan Ik;Kim, Jae Hun
Journal of Trauma and Injury
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v.33
no.2
/
pp.74-80
/
2020
Purpose: This study was conducted to investigate whether rapid and efficient administration of blood products was achieved and whether clinical outcomes were improved by applying a massive transfusion protocol (MTP). Methods: From January 2016 to September 2019, the medical records of trauma patients who received at least 10 units of packed red blood cells (PRBC) at Pusan National University Hospital (level I trauma center) were retrospectively reviewed. The patients treated from January 2016 to January 2018 were designated as the non-MTP group, and those treated from February 2018 to September 2019 were designated as the MTP group. Results: During the study period, 370 patients received massive transfusions. The non-MTP and MTP groups comprised 84 and 55 patients, respectively. No significant between-group differences were found in the units of PRBC (23.2 vs. 25.3, respectively; p=0.46), fresh frozen plasma (FFP) (21.1 vs. 24.4, respectively; p=0.40), and platelets (PLT) (15.4 vs. 17.0, respectively; p=0.54) administered in the first 24 hours. No statistically significant differences between the non-MTP and MTP groups were found in the FFP-to-PRBC ratio (0.9 vs. 0.94, respectively; p=0.44) and or the PLT-to-PRBC ratio (0.72 vs. 0.72, respectively; p=0.21). However, the total number of cryoprecipitate units was significantly higher in the MTP group than in the non-MTP group (7.4 vs. 15.3 units, respectively; p=0.003) and the ratio of cryoprecipitate to PRBC in the MTP group was significantly higher than in the non-MTP group (0.31 vs. 0.62, respectively; p=0.021). The time to transfusion was significantly reduced after MTP implementation (41.0 vs. 14.9 minutes, respectively; p=0.003). Conclusions: Although no significant differences were found in the clinical outcomes of patients who had undergone severe trauma, rapid and balanced transfusion was achieved after implementing the MTP.
Choi, Ho Yong;Hyun, Seung-Jae;Kim, Ki-Jeong;Jahng, Tae-Ahn;Kim, Hyun-Jib
Journal of Korean Neurosurgical Society
/
v.60
no.1
/
pp.75-81
/
2017
Objective : Spinal deformity surgery has the potential risk of massive blood loss. To reduce surgical bleeding, the use of tranexamic acid (TXA) became popular in spinal surgery, recently. The purpose of this study was to determine the effectiveness of intra-operative TXA use to reduce surgical bleeding and transfusion requirements in spinal deformity surgery. Methods : A total of 132 consecutive patients undergoing multi-level posterior spinal segmental instrumented fusion (${\geq}5$ levels) were analyzed retrospectively. Primary outcome measures included intraoperative estimated blood loss (EBL), transfusion amount and rate of transfusion. Secondary outcome measures included postoperative transfusion amount, rate of transfusion, and complications associated with TXA or allogeneic blood transfusions. Results : The number of patients was 89 in TXA group and 43 in non-TXA group. There were no significant differences in demographic or surgical traits between the groups except hypertension. The EBL was significantly lower in TXA group than non-TXA group (841 vs. 1336 mL, p=0.002). TXA group also showed less intra-operative and postoperative transfusion requirements (544 vs. 812 mL, p=0.012; 193 vs. 359 mL, p=0.034). Based on multiple regression analysis, TXA use could reduce surgical bleeding by 371 mL (37 % of mean EBL). Complication rate was not different between the groups. Conclusion : TXA use can effectively reduce the amount of intra-operative bleeding and transfusion requirements in spinal deformity surgery. Future randomized controlled study could confirm the routine use of TXA in major spinal surgery.
Kim, Maru;Kim, Joongsuck;Kim, Sung Jeep;Cho, Hang Joo
Journal of Trauma and Injury
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v.30
no.1
/
pp.12-15
/
2017
A 58-year-old male visited our emergency room for multiple traumas from explosion. On initial evaluation, hemopneumoperitoneum with liver laceration (grade 4) and colon perforation was identified. Hemopericardium with cardiac tamponade was also identified. Shrapnel was detected in the right ventricle. Damage control surgery was planned due to condition of hypotension. In operation room, control over bleeding was achieved after sternotomy, pericardiotomy, and laparotomy. Massive transfusion was done during operation. After gauze packing, operation was terminated with temporary closure (TC). Sanguineous fluid was drained profusely. Disseminated intravascular coagulopathy was confirmed through laboratory findings. No extravasation was discovered at hepatic angiogram. On re-operation, there was no active bleeding but oozing from sternotomy site was identified. Bone bleeding was impossible to control. Finally, reoperation was ended after gauze packing and TC all over again. The patient could survive for only a day after re-operation.
Purpose: Massive transfusion protocols (MTPs) implementation improves clinical outcomes of the patient's resuscitation with hemorrhagic trauma. Various predictive scoring system have been used and studied worldwide to improve clinical decision. However, such research has not yet been studied in Korea. This systematic review aimed to assess the predictors of MTPs activation in patients with trauma in Korea. Methods: The PubMed, Embase, Cochrane Library, Research Information Sharing Service databases, KoreaMed, and KMbase were searched from November 2022. All studies conducted in Korea that utilized predictors of MTPs activation in adult patients with trauma were included. Results: Ten articles were eligible for analysis, and the predictors were assessed. Clinical assessments such as systolic and diastolic blood pressure, shock index (SI), prehospital modified SI, modified early warning system (MEWS) and reverse SI multiplied by the Glasgow Coma Scale (rSIG) were used. Laboratory values such as lactate level, fibrinogen degradation product/fibrinogen ratio, and rotational thromboelastometry (ROTEM) were used. Imaging examinations such as pelvic bleeding score were used as predictors of MTPs activation. Conclusions: Our systematic review identified predictors of MTPs activation in patients with trauma in Korea; predictions were performed using tools that requires clinical assessments, laboratory values or imaging examinations only. Among them, ROTEM, rSIG, MEWS, SI, and lactate level showed good effects for predictions of MTPs activation. The application of predictors for MTP's activation should be individualized based on hospital resource and skill set, also should be performed as a clinical decision supporting tools.
This study was prospectively planned to realize the reduction of calcium ion in serum along with the cardiopulmonary bypass[CPB], to find out the cause of the reduction, and to verify the justification of the classical methods of calcium replacement. Nine patients with various open heart surgeries by CPB in 1987 wee selected at random. Calcium chloride was added as follows:: For each unit of ACD blood transfusion, 600mg of calcium chloride was added. In case of massive transfusion, 600 mg of calcium chloride was injected every 2 or 3 units of transfusion. On occasions such as weaning from CPB, or following defibrillation, or hypotension, weak myocardial contractility of the heart, calcium chloride was needed in an amount of 10 mg / kg. In ICU, calcium chloride was limited to use in low serum level or in emergency use. Total calcium decreased early bypass and progressively increased above the preoperative value during late bypass and three hours thereafter, Ionized calcium increased during late bypass and three hours following. Total and ionized calcium depicted similar patterns of change during open heart surgery. Decrease of the calcium at the early bypass was thought from reduction of total protein and alkalosis during bypass. Meanwhile, increase of both calciums during the end of surgery was presumably attributable to addition of calcium chloride in priming solution, injections of calcium chloride in the process of termination of bypass. We conclude that enough calcium was replaced by the classical methods of calcium supplement.
It is uncommon for pediatric patients with rhabdomyosarcoma to present with clinical and/or laboratory features of disseminated intravascular coagulation (DIC). We report a case of metastatic alveolar rhabdomyosarcoma with severe bleeding because of DIC in a 13-year-old boy. He experienced persistent oozing at the site of a previous operation, gross hematuria, and massive epistaxis. Two weeks after initiating combination chemotherapy consisting of vincristine, doxorubicin, and cyclophosphamide, the patients' laboratory indications of DIC began to resolve. During this period, the patient received massive blood transfusion of a total of 311 units (26 units of red blood cells, 26 units of fresh frozen plasma, 74 units of platelet concentrates, 17 units of single donor platelets, and 168 units of cryoprecipitate), antithrombin-III and a synthetic protease inhibitor. Despite chemotherapy and radiation therapy, he died 1 year later because of disease progression. In children with metastatic rhabdomyosarcoma and massive DIC, prompt chemotherapy and aggressive supportive care is important to decrease malignancy-triggered procoagulant activities.
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