Más de transfusión masiva / More on massive transfusion

Abril 20, 2017. No. 2665

La implementación del protocolo de tratamiento para hemorragia masiva reduce la mortalidad en pacientes no traumatizados Implementation of a management protocol for massive bleeding reduces mortality in non-trauma patients: Results from a single centre audit. [Article in English, Spanish] Martínez-Calle N1, Hidalgo F2, Alfonso A1, Muñoz M3, Hernández M1, Lecumberri R1, Páramo JA4. Med Intensiva. 2016 Dec;40(9):550-559. doi: 10.1016/j.medin.2016.05.003. Epub 2016 Jul 15. Abstract OBJECTIVE: To audit the impact upon mortality of a massive bleeding management protocol (MBP) implemented in our center since 2007. DESIGN: A retrospective, single-center study was carried out. Patients transfused after MBP implementation (2007-2012, Group 2) were compared with a historical cohort (2005-2006, Group 1). BACKGROUND: Massive bleeding is associated to high mortality rates. Available MBPs are designed for trauma patients, whereas specific recommendations in the medical/surgical settings are scarce. PATIENTS: After excluding patients who died shortly (<6h) after MBP activation (n=20), a total of 304 were included in the data analysis (68% males, 87% surgical). INTERVENTIONS: Our MBP featured goal-directed transfusion with early use of adjuvant hemostatic medications. VARIABLES OF INTEREST: Primary endpoints were 24-h and 30-day mortality. Fresh frozen plasma-to-red blood cells (FFP:RBC) and platelet-to-RBC (PLT:RBC) transfusion ratios, time to first FFP unit and the proactive MBP triggering rate were secondary endpoints. RESULTS: After MBP implementation (Group 2; n=222), RBC use remained stable, whereas FFP and hemostatic agents increased, when compared with Group 1 (n=82). Increased FFP:RBC ratio (p=0.053) and earlier administration of FFP (p=0.001) were also observed, especially with proactive MBP triggering. Group 2 patients presented lower rates of 24-h (0.5% vs. 7.3%; p=0.002) and 30-day mortality (15.9% vs. 30.2%; p=0.018) - the greatest reduction corresponding to non-surgical patients. Logistic regression showed an independent protective effect of MBP implementation upon 30-day mortality (OR=0.3; 95% CI 0.15-0.61). CONCLUSIONS: These data suggest that the implementation of a goal-directed MBP for prompt and aggressive management of non-trauma, massive bleeding patients is associated to reduced 24-h and 30-day mortality rates. KEYWORDS: Hemorragia no traumática; Hemostasia; Hemostatics; Massive bleeding protocol; Mortalidad; Mortality; Non-trauma bleeding; Protocolo de hemorragia masiva; Tasa transfusional; Transfusion ratio PDF  Uso del protocolo de transfusión masiva en pacientes civiles con y sin trauma. ¿Qué se puede hacer mejor? The use of massive transfusion protocol for trauma and non-trauma patients in a civilian setting: what can be done better? Wijaya R1, Cheng HM2, Chong CK1. Singapore Med J. 2016 May;57(5):238-41. doi: 10.11622/smedj.2016088.Abstract INTRODUCTION: Massive transfusion protocol (MTP) is increasingly used in civilian trauma cases to achieve better haemostatic resuscitation in patients requiring massive blood transfusions (MTs), with improved survival outcomes. However, in non-trauma patients, evidence for MTP is lacking. This study aims to assess the outcomes of a newly established MTP in a civilian setting, for both trauma and non-trauma patients, in an acute surgical care unit. METHODS: A retrospective cohort analysis was performed on 46 patients for whom MTP was activated in Changi General Hospital, Singapore. The patients were categorised into trauma and non-trauma groups. Assessment of Blood Consumption (ABC) score was used to identify MTP trauma patients and analyse over-activation rates. RESULTS: Only 39.1% of all cases with MTP activation eventually received MTs; 39.8% of the MTs were for non-trauma patients. Mean fresh frozen plasma to packed red blood cells (pRBC) ratio achieved with MTP was 0.741, while mean platelet to pRBC ratio was 0.213. The 24-hour mortality rate for all patients who received an MT upon MTP activation was 33.3% (trauma vs. non-trauma group: 45.5% vs. 14.3%). The ABC scoring system used for trauma patients had a sensitivity and specificity of 81.8% and 41.2%, respectively. CONCLUSION: MTP may be used for both trauma and non-trauma patients in acute care surgery. Scoring systems to predict the need for an MT, improved compliance to predefined transfusion ratios and regular reviews of the MTP are necessary to optimise MTPs and to improve the outcomes of patients receiving MTs. KEYWORDS: blood components; massive transfusion protocol; mortality; scoring system; trauma PDF Reanimación del trauma que requiere transfusión masiva: un análisis descriptivo del papel de la relación y del tiempo. Trauma resuscitation requiring massive transfusion: a descriptive analysis of the role of ratio and time. Peralta R1, Vijay A1, El-Menyar A2, Consunji R1, Abdelrahman H1, Parchani A1, Afifi I1, Zarour A3, Al-Thani H1, Latifi R4. World J Emerg Surg. 2015 Aug 14;10:36. doi: 10.1186/s13017-015-0028-3. eCollection 2015 Abstract OBJECTIVE: We aimed to evaluate whether early administration of high plasma to red blood cells ratios influences outcomes in injured patients who received massive transfusion protocol (MTP).  CONCLUSIONS: Aggressive attainment of high FFP/PRBC ratios as early as 4 h post-injury can substantially improve outcomes in trauma patients. KEYWORDS: Massive transfusion protocol; Outcome; Transfusion ratio; Trauma PDF

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Hemorragia obstétrica / Obstetric hemorrhage

Abril 21, 2017. No. 2666

Manejo del sangrado masivo en pacientes obstétricas Testigos de Jehova. La abrumadora importancia de un protocolo multidisciplinario preestablecido. Management of massive bleeding in a Jehovah's Witness obstetric patient: the overwhelming importance of a pre-established multidisciplinary protocol. Belaouchi M1, Romero E1, Mazzinari G1, Esparza M1, García-Cebrían C1, Gil F2, Muñoz M3. Blood Transfus. 2016 Jul 12;14(6):541-544. doi: 10.2450/2016.0229-15. [Epub ahead of print] Introduction Life-threatening massive bleeding is doubtlessly one of the biggest challenges in health care, especially in patients who reject allogeneic transfusion, such as Jehovah's Witnesses. However, according to the principle of patients' autonomy, our job is to accept their decision and provide them with the best possible assistance. We present a protocol for the management of massive post-operative bleeding successfully applied in a Jehovah's Witness after a Caesarean section (CS). PDF Listas de verificación y desempeño multidisciplinario del equipo durante la hemorragia obstétrica simulada. Checklists and multidisciplinary team performance during simulated obstetric hemorrhage. Hilton G1, Daniels K2, Goldhaber-Fiebert SN3, Lipman S3, Carvalho B3, Butwick A3. Int J Obstet Anesth. 2016 Feb;25:9-16. doi: 10.1016/j.ijoa.2015.08.011. Epub 2015 Aug 21. Abstract BACKGROUND: Checklists can optimize team performance during medical crises. However, there has been limited examination of checklist use during obstetric crises. In this simulation study we exposed multidisciplinary teams to checklist training to evaluate checklist use and team performance during a severe postpartum hemorrhage. METHODS: Fourteen multidisciplinary teams participated in a postpartum hemorrhage simulation occurring after vaginal delivery. Before participating, each team received checklist training. The primary study outcome was whether each team used the checklist during the simulation. Secondary outcomes were the times taken to activate our institution-specific massive transfusion protocol and commence red blood cell transfusion, and whether a designated checklist reader was used. RESULTS: The majority of teams (12/14 (86%)) used the checklist. Red blood cell transfusion was administered by all teams. The median [IQR] times taken to activate the massive transfusion protocol and transfuse red blood cells were 5min 14s [3:23-6:43] and 14min 40s [12:56-17:28], respectively. A designated checklist reader was used by 7/12 (58%) teams that used the checklist. Among teams that used a checklist with versus without a designated reader, we observed no differences in the times to activate the massive transfusion protocol or to commence red blood cell transfusion (P>0.05). CONCLUSIONS: Although checklist training was effective in promoting checklist use, multidisciplinary teams varied in their scope of checklist use during a postpartum hemorrhage simulation. Future studies are required to determine whether structured checklist training can result in more standardized checklist use during a postpartum hemorrhage. KEYWORDS: Checklist; Multidisciplinary; Obstetrics; Postpartum hemorrhage; Simulation PDF  Manejo transfusional y de la coagulación en hemorragia obstétrica severa Transfusion and coagulation management in major obstetric hemorrhage. Butwick AJ1, Goodnough LT. Curr Opin Anaesthesiol. 2015 Jun;28(3):275-84. doi: 10.1097/ACO.0000000000000180. Abstract PURPOSE OF REVIEW: Major obstetric hemorrhage is a leading cause of maternal morbidity and mortality. We will review transfusion strategies and the value of monitoring the maternal coagulation profile during severe obstetric hemorrhage. RECENT FINDINGS: Epidemiologic studies indicate that rates of severe postpartum hemorrhage (PPH) in well resourced countries are increasing. Despite these increases, rates of transfusion in obstetrics are low (0.9-2.3%), and investigators have questioned whether a predelivery 'type and screen' is cost-effective for all obstetric patients. Instead, blood ordering protocols specific to obstetric patients can reduce unnecessary antibody testing. When severe PPH occurs, a massive transfusion protocol has attracted interest as a key therapeutic resource by ensuring sustained availability of blood products to the labor and delivery unit. During early postpartum bleeding, recent studies have shown that hypofibrinogenemia is an important predictor for the later development of severe PPH. Point-of-care technologies, such as thromboelastography and rotational thromboelastometry, can identify decreased fibrin clot quality during PPH, which correlate with low fibrinogen levels. SUMMARY: A massive transfusion protocol provides a key resource in the management of severe PPH. However, future studies are needed to assess whether formula-driven vs. goal-directed transfusion therapy improves maternal outcomes in women with severe PPH. PDF Foro Internacional de Medicina Crítica Ciudad de México, Julio 13-15, 2017 Información / Information

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Neurotoxicidad por anestesia / Anesthesia neurotoxicity

Mayo 3, 2017. No. 2678

El precondicionamiento isquémico remoto provee neuroprotección. Impacto de la apoptosis inducida por ketamina en el cerebro de ratas en desarrollo Remote ischemic preconditioning provides neuroprotection: impact on ketamine-induced neuroapoptosis in the developing rat brain. Ma W1, Cao YY, Qu S, Ma SS, Wang JZ, Deng LQ, Yuan WJ, Meng JH. Eur Rev Med Pharmacol Sci. 2016 Dec;20(23):4972-4979. Abstract OBJECTIVE: Previous studies have demonstrated that the commonly used anesthetic ketamine can acutely increase apoptosis and have long-lasting detrimental effects on cognitive function as the animal matures. Remote ischemic preconditioning (RIPC) has been confirmed to have a cerebral protective role in animal models of brain damage. The aim of this study was to investigate whether RIPC can protect the developing brain from anesthetic-induced neurotoxicity. MATERIALS AND METHODS: To investigate the protective properties of RIPC, 60 new-born Sprague-Dawley (SD) rats were randomly allocated into four groups: ketamine (20 mg/kg was diluted in saline, six times at an interval of 2 hours); RIPC (left hind row ischemia 5 min, reperfusion 5 min, a total of four cycles); ketamine + RIPC: RIPC was induced at postnatal day 5 and rats underwent the same treatment with the ketamine group after 48 hours; and saline (group vehicle). Neuronal apoptosis in the frontal cortex and hippocampal CA1 region was measured 24 h after treatment using immunohistochemistry of cleaved caspase-3. Learning and memory abilities were tested at the age of 60 days by Morris water maze test. RESULTS: The percentage of cleaved caspase-3 immunohistochemical staining positive cells in the ketamine + RIPC group showed a more marked decline in neuronal apoptosis of the CA1 region than that in the ketamine group (p < 0.05) but not in the CA1 region (p > 0.05). The mice exposed to RIPC alone showed no difference from the saline-treated mice. Moreover, RIPC significantly reversed the learning and memory deficits observed at 60 days of age. CONCLUSIONS: Our data indicate that RIPC treatment provides protection against ketamine-induced neuroapoptosis in the frontal cerebral cortex but not in the hippocampal CA1 region in developing rats and attenuates long-term behavioural deficits as the animals mature, suggesting a new possible strategy for neuroprotection. PDF Monóxido de carbono y neurotoxicidad inducida por anestesia Carbon monoxide and anesthesia-induced neurotoxicity. Levy RJ1. Neurotoxicol Teratol. 2017 Mar - Apr;60:50-58. doi: 10.1016/j.ntt.2016.09.002. Epub 2016 Sep 9. Abstract The majority of commonly used anesthetic agents induce widespread neuronal degeneration in the developing mammalian brain. Downstream, the process appears to involve activation of the oxidative stress-associated mitochondrial apoptosis pathway. Targeting this pathway could result in prevention of anesthetic toxicity in the immature brain. Carbon monoxide (CO) is a gas that exerts biological activity in the developing brain and low dose exposures have the potential to provide neuroprotection. In recent work, low concentration CO exposures limited isoflurane-induced neuronal apoptosis in a dose-dependent manner in newborn mice and modulated oxidative stress within forebrain mitochondria. Because infants and children are routinely exposed to low levels of CO during low-flow general endotracheal anesthesia, such anti-oxidant and pro-survival cellular effects are clinically relevant. Here we provide an overview of anesthesia-related CO exposure, discuss the biological activity of low concentration CO, detail the effects of CO in the brain during development, and provide evidence for CO-mediated inhibition of anesthesia-induced neurotoxicity. KEYWORDS: Anesthesia-induced neurotoxicity; Apoptosis; Carbon monoxide; Cytoprotection; Endogenous; Exogenous; Exposure; General anesthesia; Low-flow anesthesia; Mitochondria; Oxidative stress; Therapy PDF Neurotoxicidad inducida por anestesia en el cerebro en desarrollo. Actualización de la evidencia preclínica Anaesthetics-induced neurotoxicity in developing brain: an update on preclinical evidence. Zhou Z1, Ma D2. Brain Sci. 2014 Mar 14;4(1):136-49. doi: 10.3390/brainsci4010136. Abstract Every year millions of young people are treated with anaesthetic agents for surgery and sedation in a seemingly safe manner. However, growing and convincing preclinical evidence in rodents and nonhuman primates, together with recent epidemiological observations, suggest that exposure to anaesthetics in common clinical use can be neurotoxic to the developing brain and lead to long-term neurological sequelae. These findings have seriously questioned the safe use of general anaesthetics in obstetric and paediatric patients. The mechanisms and human applicability of  anaesthetic neurotoxicity and neuroprotection have remained under intense investigation over the past decade. Ongoing pre-clinical investigation may have significant impact on clinical practice in the near future. This review represents recent developments in this rapidly emerging field. The aim is to summarise recently available laboratory data, especially those being published after 2010, in the field of anaesthetics-induced neurotoxicity and its impact on cognitive function. In addition, we will discuss recent findings in mechanisms of early-life anaesthetics-induced neurotoxicity, the role of human stem cell-derived models in detecting such toxicity, and new potential alleviating strategies. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org