Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies

Anesthesiology (Impact Factor: 5.88). 07/2006; 105(1):198-208. DOI: 10.1097/00000542-200607000-00030
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    ABSTRACT: Trauma is a leading cause of mortality and morbidity, with traumatic brain injury (TBI) and uncontrolled hemorrhage responsible for the majority of these deaths. Recombinant activated factor VIIa (rFVIIa) is being investigated as an adjunctive hemostatic treatment for bleeding refractory to conventional replacement therapy in trauma patients. TBI is a common component of polytrauma injuries. However, the combination of TBI with polytrauma injuries is associated with specific risk factors and treatment modalities somewhat different from those of polytrauma without TBI. Although rFVIIa treatment may offer added potential benefit for patients with combined TBI and polytrauma, its safety in this population has not yet been assessed. We conducted a post hoc sub analysis of patients with TBI and severe blunt polytrauma enrolled into a prospective, international, double-blind, randomized, placebo-controlled study. A post hoc analysis of study data was performed for 143 patients with severe blunt trauma enrolled in a prospective, randomized, placebo-controlled study, evaluating the safety and efficacy of intravenous rFVIIa (200 + 100 + 100 microg/kg) or placebo, to identify patients with a computed tomography (CT) diagnosis of TBI. The incidences of ventilator-free days, intensive care unit-free days, and thromboembolic, serious, and adverse events within the 30-day study period were assessed in this cohort. Thirty polytrauma patients (placebo, n = 13; rFVIIa, n = 17) were identified as having TBI on CT. No significant differences in rates of mortality (placebo, n = 6, 46%, 90% confidence interval (CI): 22% to 71%; rFVIIa, n = 5, 29%, 90% CI: 12% to 56%; P = 0.19), in median numbers of intensive care unit-free days (placebo = 0, rFVIIa = 3; P = 0.26) or ventilator-free days (placebo = 0, rFVIIa = 10; P = 0.19), or in rates of thromboembolic adverse events (placebo, 15%, 90% CI: 3% to 51%; rFVIIa, 0%, 90% CI: 0% to 53%; P = 0.18) or serious adverse events (placebo, 92%, 90% CI: 68% to 98%; rFVIIa, 82%, 90% CI: 60% to 92%; P = 0.61) were observed between treatment groups. The use of a total dose of 400 (200 + 100 + 100) microg/kg rFVIIa in this group of hemodynamically unstable polytrauma patients with TBI was not associated with an increased risk of mortality or with thromboembolic or adverse events.
    Critical care (London, England) 02/2007; 11(4):R85. DOI:10.1186/cc6092 · 4.48 Impact Factor
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    ABSTRACT: Homologe Blutkonserven sind heute sehr sicher. Deshalb spielen die Kosten bei der Entscheidung zur Transfusion eine dominierende Rolle. Die klinische Physiologie hat maßgeblich dazu beigetragen, dass das mehrere Jahrzehnte gültige Dogma bei einer Hämoglobinkonzentration (cHb) unter 6,21 mmol/l (10 g/dl) Erythrozyten zu substituieren gefallen ist. Dennoch wird nach wie vor großzügig transfundiert. Dies geht aus den Daten großer Zentren hervor, die sich auf die Behandlung von Zeugen Jehovahs spezialisiert haben, Patienten, die eine Bluttransfusion unter allen Umständen ablehnen. Gleichwohl werden sie mit dem gleichen Erfolg auch exzessiven operativen und onkologischen Behandlungsverfahren zugeführt. Diese Daten sind Fakt und müssen vor dem Hintergrund des enormen Kostendrucks, der auf den Kliniken liegt, wertfrei diskutiert werden.
    Der Anaesthesist 04/2007; 56(4):380-384. DOI:10.1007/s00101-007-1159-z · 0.76 Impact Factor
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    ABSTRACT: The perioperative care of patients undergoing liver transplantation is a crucial clinical situation encountered by surgeons, anesthetists, and critical care physicians. Great strides have been made in the field of liver transplantation since the time when it was considered just an experimental procedure [1]. Liver transplantationrelated mortality and complication rates have significantly decreased and the mean 1-year survival rate is now more than 90% as a result of improved techniques, the consolidation of basic knowledge and experience, better patient selection and preparation, and the use of innovative drugs and technologies [2]. Morbidity after liver transplantation results in suffering, prolonged hospitalization, and increased health care expenditure. Associated conditions, such as acute lung injury (ALI), renal dysfunction, infection, and gastrointestinal tract dysfunction, increase hospital length of stay and costs. Graft-related complications, such as primary non-function, poor (or delayed) early graft function, and early rejection, can result in the loss of the donor organ reducing dramatically the outcome or necessitating retransplantation. Complications after liver transplantation are likely to be multifactorial in origin. Some of the morbidity may be due to a patient’s underlying condition, for example, their preoperative renal function, the United Network for Organ Sharing (UNOS) status, and their model for end-stage liver disease (MELD) score. We will discuss some particular aspects of the early intensive care unit (ICU) management of the liver transplanted patient that reflect the current challenges associated with this procedure including early extubation and non-invasive ventilation; hemodynamic management, splanchnic perfusion, and graft function; fluid management and transfusion; lung and liver function; renal function; and neurological status and sedation.
    Intensive Care Medicine, 12/2007: pages 763-776;
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