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Estcourt LJ, Desborough M, Doree C, Hopewell S, Trivella M, Stanworth SJ. Plasma transfusions prior to lumbar punctures and epidural catheters for people with abnormal coagulation. Cochrane Database Syst Rev 2017. [DOI: 10.1002/14651858.cd012497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Acker JP, Marks DC, Sheffield WP. Quality Assessment of Established and Emerging Blood Components for Transfusion. JOURNAL OF BLOOD TRANSFUSION 2016; 2016:4860284. [PMID: 28070448 PMCID: PMC5192317 DOI: 10.1155/2016/4860284] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/02/2016] [Indexed: 12/16/2022]
Abstract
Blood is donated either as whole blood, with subsequent component processing, or through the use of apheresis devices that extract one or more components and return the rest of the donation to the donor. Blood component therapy supplanted whole blood transfusion in industrialized countries in the middle of the twentieth century and remains the standard of care for the majority of patients receiving a transfusion. Traditionally, blood has been processed into three main blood products: red blood cell concentrates; platelet concentrates; and transfusable plasma. Ensuring that these products are of high quality and that they deliver their intended benefits to patients throughout their shelf-life is a complex task. Further complexity has been added with the development of products stored under nonstandard conditions or subjected to additional manufacturing steps (e.g., cryopreserved platelets, irradiated red cells, and lyophilized plasma). Here we review established and emerging methodologies for assessing blood product quality and address controversies and uncertainties in this thriving and active field of investigation.
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Affiliation(s)
- Jason P. Acker
- Centre for Innovation, Canadian Blood Services, Edmonton, AB, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Denese C. Marks
- Research and Development, Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - William P. Sheffield
- Centre for Innovation, Canadian Blood Services, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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Plasma Transfusion in Patients With Cirrhosis in China: A Retrospective Multicenter Cohort Study. Transfus Med Rev 2016; 31:107-112. [PMID: 28063764 DOI: 10.1016/j.tmrv.2016.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/29/2016] [Accepted: 11/29/2016] [Indexed: 12/19/2022]
Abstract
Patients with cirrhosis used to be associated with frequent use of blood components because of their complex disorder of hemostasis and bleeding complications. Recent findings have indicated that patients with cirrhosis have a state of "rebalanced" or even procoagulant hemostasis and have questioned the prophylactic use of plasma. To evaluate the current status of plasma use in patients with cirrhosis, we conducted a retrospective survey in 11 tertiary-care hospitals in China from September 1 to October 31, 2013. All patients admitted with cirrhosis during the study period were included in the study. The survey collected information including patients' diagnostic and demographic data, clinical course including bleeding complications and invasive procedures, laboratory results, and plasma transfusion data. Among 1595 patients with cirrhosis admitted to the 11 hospitals, 236 (14.8%) patients received 1 or more plasma transfusions during the study period. The number of plasma transfusions is defined as the number of transfusion orders. A total of 1037 plasma transfusions were administered to these patients, with a mean of 4.4 transfusions per transfused patient, ranging from 1 to 22 transfusions per transfused patient. Most plasma transfusions (760/1037; 73.3%) were given to patients without bleeding, for treatment of coagulopathy either without planned invasive procedures (70.4%) or before invasive procedures (2.9%). The median dose of plasma transfusion was 3.8 mL/kg. The rate of plasma transfusion of participating hospitals varied from 5.3% to 31.8%. It is encouraging to see that in one teaching hospital, 85.7% plasma transfusions were given to patients with bleeding indication, showing a promising sign in appropriate transfusion. Prophylaxis or empirical plasma transfusion is still a common problem in managing patients with liver cirrhosis. Wide variations are found in plasma transfusion practice among hospitals. Effective measures to control and reduce empirical correction of abnormal coagulation tests through transfusing plasma should be strengthened urgently.
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New HV, Berryman J, Bolton-Maggs PHB, Cantwell C, Chalmers EA, Davies T, Gottstein R, Kelleher A, Kumar S, Morley SL, Stanworth SJ. Guidelines on transfusion for fetuses, neonates and older children. Br J Haematol 2016; 175:784-828. [DOI: 10.1111/bjh.14233] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Helen V. New
- NHS Blood and Transplant; London UK
- Imperial College Healthcare NHS Trust; London UK
| | | | | | | | | | | | - Ruth Gottstein
- St. Mary's Hospital; Manchester/University of Manchester; Manchester UK
| | | | - Sailesh Kumar
- Mater Research Institute; University of Queensland; Brisbane Australia
| | - Sarah L. Morley
- Addenbrookes Hospital/NHS Blood and Transplant; Cambridge UK
| | - Simon J. Stanworth
- Oxford University Hospitals NHS Trust/NHS Blood and Transplant; Oxford UK
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55
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Kozek-Langenecker S. Clinical efficacy of fresh frozen plasma compared with coagulation factor concentrates for treating coagulopathy in patients with massive bleeding. Med Intensiva 2016; 40:371-3. [DOI: 10.1016/j.medin.2016.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 01/10/2016] [Accepted: 01/13/2016] [Indexed: 02/07/2023]
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56
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Warner MA, Woodrum DA, Hanson AC, Schroeder DR, Wilson GA, Kor DJ. Prophylactic Plasma Transfusion Before Interventional Radiology Procedures Is Not Associated With Reduced Bleeding Complications. Mayo Clin Proc 2016; 91:1045-55. [PMID: 27492911 PMCID: PMC4982754 DOI: 10.1016/j.mayocp.2016.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/15/2016] [Accepted: 05/04/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the association between prophylactic plasma transfusion and periprocedural red blood cell (RBC) transfusion rates in patients with elevated international normalized ratio (INR) values undergoing interventional radiology procedures. PATIENTS AND METHODS In this retrospective cohort study, adult patients undergoing interventional radiology procedures with a preprocedural INR available within 30 days of the procedure during a study period of January 1, 2009, to December 31, 2013, were eligible for inclusion. Baseline characteristics, coagulation parameters, transfusion requirements, and procedural details were extracted. Univariate and multivariable propensity-matched analyses were used to assess the relationships between prophylactic plasma transfusion and the outcomes of interest, with a primary outcome assessed a priori of RBC transfusion occurring during the procedure or within the first 24 hours postprocedurally. RESULTS A total of 18,204 study participants met inclusion criteria for this study, and 1803 (9.9%) had an INR of 1.5 or greater before their procedure. Of these 1803 patients, 196 patients (10.9%) received prophylactic plasma transfusion with a median time of 1.9 hours (interquartile range [IQR], 1.1-3.2 hours) between plasma transfusion initiation and procedure initiation. In multivariable propensity-matched analysis, plasma administration was associated with increased periprocedural RBC transfusions (odds ratio, 2.20; 95% CI, 1.38-3.50; P<.001) and postprocedural intensive care unit admission rates (odds ratio, 2.11; 95% CI, 1.41-3.14; P<.001) as compared with those who were not transfused preprocedurally. Similar relationships were seen at higher INR thresholds for plasma transfusion. CONCLUSION In patients undergoing interventional radiology procedures, preprocedural plasma transfusions given in the setting of elevated INR values were associated with increased periprocedural RBC transfusions. Additional research is needed to clarify this potential association between preprocedural plasma transfusion and periprocedural RBC transfusion.
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Affiliation(s)
- Matthew A Warner
- Department of Anesthesiology, Mayo Clinic, Rochester, MN; Periprocedural Outcomes, Information and Transfusion Study Group, Mayo Clinic, Rochester, MN
| | - David A Woodrum
- Department of Vascular and Interventional Radiology, Mayo Clinic, Rochester, MN
| | - Andrew C Hanson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Gregory A Wilson
- Periprocedural Outcomes, Information and Transfusion Study Group, Mayo Clinic, Rochester, MN; Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, MN
| | - Daryl J Kor
- Department of Anesthesiology, Mayo Clinic, Rochester, MN; Periprocedural Outcomes, Information and Transfusion Study Group, Mayo Clinic, Rochester, MN.
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Keir AK, Stanworth SJ. Neonatal Plasma Transfusion: An Evidence-Based Review. Transfus Med Rev 2016; 30:174-82. [PMID: 27473518 DOI: 10.1016/j.tmrv.2016.07.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 07/04/2016] [Accepted: 07/04/2016] [Indexed: 01/31/2023]
Abstract
Several clinical scenarios for plasma transfusion are repeatedly identified in audits, including treatment of bleeding in association with laboratory evidence of coagulopathy, correction of disseminated intravascular coagulation, prevention of intraventricular hemorrhage, management of critically ill neonates (eg, during sepsis or as a volume expander), or correction of markers of prolonged coagulation in the absence of bleeding. The findings of at least one national audit of transfusion practice indicated that almost half of plasma transfusions are given to neonates with abnormal coagulation values with no evidence of active bleeding, despite the limited evidence base to support the effectiveness of this practice. Plasma transfusions to neonates should be considered in the clinical context of bleeding (eg, vitamin K dependent), disseminated intravascular coagulation, and very rare inherited deficiencies of coagulation factors. There seems to be no role for prophylactic plasma to prevent intraventricular hemorrhage or for use as a volume expander.
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Affiliation(s)
- Amy K Keir
- Robinson Research Institute and the School of Medicine, University of Adelaide, Adelaide, Australia; Women's and Children's Health Network, North Adelaide, South Australia, Australia.
| | - Simon J Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Trust, Oxford, United Kingdom.
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Thakkar RN, Lee KK, Ness PM, Wintermeyer TL, Johnson DJ, Liu E, Rajprasad A, Knight AM, Wachter PA, Demski R, Frank SM. Relative impact of a patient blood management program on utilization of all three major blood components. Transfusion 2016; 56:2212-20. [DOI: 10.1111/trf.13718] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/07/2016] [Accepted: 05/19/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Rajiv N. Thakkar
- Department of MedicineThe Johns Hopkins Medical InstitutionsBaltimore Maryland
| | - K.H. Ken Lee
- Armstrong Institute of Patient Safety and QualityThe Johns Hopkins Medical InstitutionsBaltimore Maryland
| | - Paul M. Ness
- Department of Pathology (Transfusion Medicine)The Johns Hopkins Medical InstitutionsBaltimore Maryland
| | - Tyler L. Wintermeyer
- Department of Clinical AnalyticsThe Johns Hopkins Medical InstitutionsBaltimore Maryland
| | - Daniel J. Johnson
- Department of Anesthesiology/Critical Care MedicineThe Johns Hopkins Medical InstitutionsBaltimore Maryland
| | - Emily Liu
- Department of Pathology (Transfusion Medicine)The Johns Hopkins Medical InstitutionsBaltimore Maryland
| | - Anjuli Rajprasad
- Armstrong Institute of Patient Safety and QualityThe Johns Hopkins Medical InstitutionsBaltimore Maryland
| | - Amy M. Knight
- Department of MedicineThe Johns Hopkins Medical InstitutionsBaltimore Maryland
| | - Pat A. Wachter
- Armstrong Institute of Patient Safety and QualityThe Johns Hopkins Medical InstitutionsBaltimore Maryland
| | - Renee Demski
- Armstrong Institute of Patient Safety and QualityThe Johns Hopkins Medical InstitutionsBaltimore Maryland
| | - Steven M. Frank
- Department of Anesthesiology/Critical Care MedicineThe Johns Hopkins Medical InstitutionsBaltimore Maryland
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59
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Tinmouth A. Assessing the Rationale and Effectiveness of Frozen Plasma Transfusions. Hematol Oncol Clin North Am 2016; 30:561-72. [DOI: 10.1016/j.hoc.2016.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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60
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Hanna JM, Keenan JE, Wang H, Andersen ND, Gaca JG, Lombard FW, Welsby IJ, Hughes GC. Use of human fibrinogen concentrate during proximal aortic reconstruction with deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2016; 151:376-82. [PMID: 26428473 PMCID: PMC5429587 DOI: 10.1016/j.jtcvs.2015.08.079] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 08/11/2015] [Accepted: 08/23/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Human fibrinogen concentrate (HFC) is approved by the Food and Drug Administration for use at 70 mg/kg to treat congenital afibrinogenemia. We sought to determine whether this dose of HFC increases fibrinogen levels in the setting of high-risk bleeding associated with aortic reconstruction and deep hypothermic circulatory arrest (DHCA). METHODS This was a prospective, pilot, off-label study in which 22 patients undergoing elective proximal aortic reconstruction with DHCA were administered 70 mg/kg HFC upon separation from cardiopulmonary bypass (CPB). Fibrinogen levels were measured at baseline, just before, and 10 minutes after HFC administration, on skin closure, and the day after surgery. The primary study outcome was the difference in fibrinogen level immediately after separation from CPB, when HFC was administered, and the fibrinogen level 10 minutes following HFC administration. Additionally, postoperative thromboembolic events were assessed as a safety analysis. RESULTS The mean baseline fibrinogen level was 317 ± 49 mg/dL and fell to 235 ± 39 mg/dL just before separation from CPB. After HFC administration, the fibrinogen level rose to 331 ± 41 mg/dL (P < .001) and averaged 372 ± 45 mg/dL the next day. No postoperative thromboembolic complications occurred. CONCLUSIONS Administration of 70 mg/kg HFC upon separation from CPB raises fibrinogen levels by approximately 100 mg/dL without an apparent increase in thrombotic complications during proximal aortic reconstruction with DHCA. Further prospective study in a larger cohort of patients will be needed to definitively determine the safety and evaluate the efficacy of HFC as a hemostatic adjunct during these procedures.
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Affiliation(s)
- Jennifer M Hanna
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey E Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Frederick W Lombard
- Division of Cardiac Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Ian J Welsby
- Division of Cardiac Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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61
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Squizzato A, Hunt BJ, Kinasewitz GT, Wada H, Ten Cate H, Thachil J, Levi M, Vicente V, D'Angelo A, Di Nisio M. Supportive management strategies for disseminated intravascular coagulation. An international consensus. Thromb Haemost 2015; 115:896-904. [PMID: 26676927 DOI: 10.1160/th15-09-0740] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 12/02/2015] [Indexed: 12/19/2022]
Abstract
The cornerstone of the management of disseminated intravascular coagulation (DIC) is the treatment of the underlying condition triggering the coagulopathy. However, a number of uncertainties remain over the optimal supportive treatment. The aim of this study was to provide evidence and expert-based recommendations on the optimal supportive haemostatic and antithrombotic treatment strategies for patients with DIC. A working group defined five relevant clinical scenarios. Published studies were systematically searched in the MEDLINE and EMBASE databases (up to May 2014). Seven internationally recognised experts were asked to independently provide clinical advice. A two-phase blinded data collection technique was used to reach consensus. Only three randomised controlled trials (RCTs) on the supportive management of DIC were identified. The RCTs (overall less than 100 patients) investigated the use of fresh frozen plasma and platelet transfusion and found no differences in survival between the intervention and control groups. The experts' approach was heterogeneous, although there was consensus that supportive management should vary according to the underlying cause, clinical manifestations and severity of blood test abnormalities. Platelet transfusion should be given to maintain platelet count > 50×10⁹/l in case of bleeding while a lower threshold of 20 to 30×10⁹/l may be used in DIC without bleeding. Thromboprophylaxis with low-molecular-weight heparin is advised until bleeding ensues or platelet count drops below 30×10⁹/l. In conclusion, in the absence of solid evidence from RCTs, an individualised supportive management of DIC is advisable based on the type of underlying disease, presence of bleeding or thrombotic complications and laboratory tests results.
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Affiliation(s)
- Alessandro Squizzato
- Alessandro Squizzato, U. O. C. Medicina I, Ospedale di Circolo, Viale Borri 57, 21100 Varese, Italy, Tel.: +39 0332 278831, E-mail: ,
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Noga T, Bruce A, Blain H, Nahirniak S. Four-factor prothrombin complex concentrates in paediatric patients - a retrospective case series. Vox Sang 2015; 110:253-7. [DOI: 10.1111/vox.12353] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 09/11/2015] [Accepted: 09/11/2015] [Indexed: 12/26/2022]
Affiliation(s)
- T. Noga
- University of Alberta Hospital; Edmonton AB Canada
- Faculty of Medicine; University of Alberta; Edmonton AB Canada
| | - A.A.K. Bruce
- Pediatric Hematology; Stollery Children's Hospital; University of Alberta; Edmonton AB Canada
- Faculty of Medicine; University of Alberta; Edmonton AB Canada
| | - H. Blain
- Transfusion Medicine; Alberta Health Services; Edmonton AB Canada
| | - S. Nahirniak
- University of Alberta Hospital; Edmonton AB Canada
- Transfusion Medicine; Alberta Health Services; Edmonton AB Canada
- Faculty of Medicine; University of Alberta; Edmonton AB Canada
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63
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Hubbard T, Backholer L, Wiltshire M, Cardigan R, Ariëns RAS. Effects of riboflavin and amotosalen photoactivation systems for pathogen inactivation of fresh-frozen plasma on fibrin clot structure. Transfusion 2015; 56:41-8. [PMID: 26358662 DOI: 10.1111/trf.13261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 07/07/2015] [Accepted: 07/09/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Fresh-frozen plasma (FFP) transfusion carries a risk of viral transmission from donor to recipient. Riboflavin (Mirasol) and amotosalen (Intercept) are two pathogen inactivation (PI) methods that may enhance the safety of FFP for transfusion. Our study investigated the effects of Mirasol and Intercept treatment on fibrin formation and clot structure. STUDY DESIGN AND METHODS FFP underwent either Mirasol or Intercept treatment, and aliquots were taken before addition of the compound, before illumination (after addition of compound only), and after treatment (addition of compound plus illumination). All samples underwent turbidimetric analysis, lysis analysis, assessment of clot permeation, and analysis by laser scanning confocal microscopy. RESULTS After treatment, there was a decrease in optical density of the fibrin network for Mirasol and Intercept, lag time to fibrin formation was prolonged for Mirasol and lysis time for Intercept, clot permeability was significantly decreased, and clot density was increased for both. CONCLUSIONS Our study shows that plasma treated with Mirasol and Intercept produces denser clots consisting of thinner fibers and warrants further studies to evaluate the clinical significance of these structural changes in fibrin clot formation.
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Affiliation(s)
- Thomas Hubbard
- Theme Thrombosis, Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre and Leeds Institute for Genetics, Health and Therapeutics, Faculty of Medicine and Health, University of Leeds, Leeds
| | | | | | | | - Robert A S Ariëns
- Theme Thrombosis, Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre and Leeds Institute for Genetics, Health and Therapeutics, Faculty of Medicine and Health, University of Leeds, Leeds
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Shah A, Amarapurkar D, Dharod M, Chandnani M, Baijal R, Kumar P, Jain M, Patel N, Kamani P, Gautam S, Shah N, Kulkarni S, Doshi S. Coagulopathy in cirrhosis: A prospective study to correlate conventional tests of coagulation and bleeding following invasive procedures in cirrhotics. Indian J Gastroenterol 2015; 34:359-64. [PMID: 26487399 DOI: 10.1007/s12664-015-0584-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 08/04/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Conventional tests of coagulation which only measure procoagulant factors do not correctly estimate the actual in vivo hemostatic balance in cirrhosis. This prospective multicenter study was conducted to evaluate safety of various invasive procedures in the presence of abnormal coagulation tests and to correlate conventional coagulation parameters with clinically significant bleeding in cirrhotics. METHODS Three hundred and eighty patients (median age 54 years, 287 males) enrolled in the study were divided into two groups (A and B), according to the presence or absence of abnormal coagulation parameters (defined as INR ≥1.5 and/or platelet count ≤50,000/cum). RESULTS One hundred and twenty-eight patients (33.68%) were qualified in group A. Alcohol was the predominant etiology of cirrhosis (40% and 32% in groups A and B, respectively). The two groups were similar in baseline characteristics other than tests of coagulation and severity of liver disease. Low risk procedures (abdominal paracentesis most common) were carried out in 47% and 53% patients in two groups, respectively. None of the patients in either group had clinically significant bleeding. Similarly, high risk procedures (central vein cannulation, liver biopsy, etc.) were carried out in 14% and 10%, respectively, in two groups. Three patients in group A developed clinically significant bleeding, however, the difference was statistically nonsignificant (p=0.061). None of our patients received periprocedural correction of abnormal coagulation parameters with plasma/platelet concentrate. CONCLUSIONS Deranged conventional coagulation parameters did not predict clinically significant bleeding in cirrhosis. Whenever indicated, any invasive procedure could be safely carried out in patients with cirrhosis without prior correction of coagulation abnormalities.
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Farach SM, Danielson PD, Chandler NM. Preprocedural Coagulation Studies in Pediatric Patients Undergoing Percutaneous Intervention for Appendiceal Abscesses. Am Surg 2015. [DOI: 10.1177/000313481508100917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The literature reports poor correlation between coagulation screening and prediction of bleeding risk in children. Our aim is to determine whether there is a role for coagulation studies in children undergoing percutaneous intervention for appendiceal abscesses. A retrospective review of 1805 patients presenting with a diagnosis of appendicitis from September 2008 to September 2013 was performed. Patients presenting with appendiceal abscess who underwent percutaneous intervention were selected for further review (n = 131). A total of 76 patients (58%) had normal coagulation studies, whereas 55 (42%) had elevated values. An international normalized ratio ≥ 1.3 was found in 26 patients. Patients with normal coagulation values had an incidence of bleeding of 1.3 per cent. In the abnormal coagulation group, 8 patients received fresh frozen plasma before intervention, whereas 47 did not. There was one hematoma noted in each group with an incidence of bleeding of 3.6 per cent. The overall incidence of hematoma was 2.3 per cent with no significant difference in bleeding risk between the normal and abnormal coagulation groups. In conclusion, although many patients are found to have elevated coagulation studies, most do not have bleeding complications after intervention. There is poor correlation between coagulation screening and postprocedural outcomes evidenced by the low risk of bleeding.
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Affiliation(s)
- Sandra M. Farach
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Saint Petersburg, Florida
| | - Paul D. Danielson
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Saint Petersburg, Florida
| | - Nicole M. Chandler
- Division of Pediatric Surgery, All Children's Hospital Johns Hopkins Medicine, Saint Petersburg, Florida
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Szpila BE, Ozrazgat-Baslanti T, Zhang J, Lanz J, Davis R, Rebel A, Vanzant E, Gentile LF, Cuenca AG, Ang DN, Liu H, Lottenberg L, Marker P, Zumberg M, Bihorac A, Moore FA, Brakenridge S, Efron PA. Successful implementation of a packed red blood cell and fresh frozen plasma transfusion protocol in the surgical intensive care unit. PLoS One 2015; 10:e0126895. [PMID: 26010247 PMCID: PMC4444010 DOI: 10.1371/journal.pone.0126895] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 04/08/2015] [Indexed: 11/19/2022] Open
Abstract
Background Blood product transfusions are associated with increased morbidity and mortality. The purpose of this study was to determine if implementation of a restrictive protocol for packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusion safely reduces blood product utilization and costs in a surgical intensive care unit (SICU). Study Design We performed a retrospective, historical control analysis comparing before (PRE) and after (POST) implementation of a restrictive PRBC/FFP transfusion protocol for SICU patients. Univariate analysis was utilized to compare patient demographics and blood product transfusion totals between the PRE and POST cohorts. Multivariate logistic regression models were developed to determine if implementation of the restrictive transfusion protocol is an independent predictor of adverse outcomes after controlling for age, illness severity, and total blood products received. Results 829 total patients were included in the analysis (PRE, n=372; POST, n=457). Despite higher mean age (56 vs. 52 years, p=0.01) and APACHE II scores (12.5 vs. 11.2, p=0.006), mean units transfused per patient were lower for both packed red blood cells (0.7 vs. 1.2, p=0.03) and fresh frozen plasma (0.3 vs. 1.2, p=0.007) in the POST compared to the PRE cohort, respectively. There was no difference in inpatient mortality between the PRE and POST cohorts (7.5% vs. 9.2%, p=0.39). There was a decreased risk of urinary tract infections (OR 0.47, 95%CI 0.28-0.80) in the POST cohort after controlling for age, illness severity and amount of blood products transfused. Conclusions Implementation of a restrictive transfusion protocol can effectively reduce blood product utilization in critically ill surgical patients with no increase in morbidity or mortality.
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Affiliation(s)
- Benjamin E. Szpila
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Tezcan Ozrazgat-Baslanti
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Jianyi Zhang
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Jennifer Lanz
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Ruth Davis
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Annette Rebel
- Department of Anesthesia, University of Kentucky College of Medicine, Lexington, KY, 40506, United States of America
| | - Erin Vanzant
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Lori F. Gentile
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Alex G. Cuenca
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Darwin N. Ang
- Department of Surgery, University of South Florida, Tampa, FL, 33612, United States of America
| | - Huazhi Liu
- Department of Surgery, University of South Florida, Tampa, FL, 33612, United States of America
| | - Lawrence Lottenberg
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Peggy Marker
- Department of Nursing, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Marc Zumberg
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Azra Bihorac
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Frederick A. Moore
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Scott Brakenridge
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
| | - Philip A. Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610, United States of America
- * E-mail:
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Pal S, Curley A, Stanworth SJ. Interpretation of clotting tests in the neonate. Arch Dis Child Fetal Neonatal Ed 2015; 100:F270-4. [PMID: 25414486 DOI: 10.1136/archdischild-2014-306196] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 11/05/2014] [Indexed: 01/01/2023]
Abstract
There are significant differences between the coagulation system in neonates compared with children and adults. Abnormalities of standard coagulation tests are common within the neonatal population. The laboratory tests of activated partial thromboplastin time (aPTT) and prothrombin time (PT) were developed to investigate coagulation factor deficiencies in patients with a known bleeding history, and their significance and applied clinical value in predicting bleeding (or thrombotic) risk in critically ill patients is weak. Routine screening of coagulation on admission to the neonatal intensive care unit leads to increased use of plasma for transfusion. Fresh frozen plasma (FFP) is a human donor plasma frozen within a short specified time period after collection (often 8 h) and then stored at -30°C. FFP has little effect on correcting abnormal coagulation tests when mild and moderate abnormalities of PT are documented in neonates. There is little evidence of effectiveness of FFP in neonates. A large trial by the Northern Neonatal Nursing Initiative assessed the use of prophylactic FFP in preterm infants and reported no improvement in clinical outcomes in terms of mortality or severe disability. An appropriate FFP transfusion strategy in neonates should be one that emphasises the therapeutic use in the face of bleeding rather than prophylactic use in association with abnormalities of standard coagulation tests that have very limited predictive value for bleeding.
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Affiliation(s)
- Sanchita Pal
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anna Curley
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Simon J Stanworth
- Department of Haematology, National Health Service Blood and Transplant/Oxford University Hospitals Trust, Headington, Oxford, UK
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68
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Woodley-Cook J, Amaral J, Connolly B, Brandão LR. Do children without a known bleeding tendency undergoing PICC placement require coagulation laboratory testing? Pediatr Radiol 2015; 45:727-35. [PMID: 25655367 DOI: 10.1007/s00247-014-3207-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 08/18/2014] [Accepted: 10/09/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Obtaining basic hemostatic laboratory investigations prior to peripherally inserted central catheter (PICC) insertion remains controversial, even if the procedure is converted to a tunneled central venous line (CVL) placement. OBJECTIVE To determine the value of pre-procedural blood screening (hemoglobin level, platelet count, aPTT/INR) in hospitalized children without a known bleeding diathesis. MATERIALS AND METHODS This retrospective review included pediatric patients undergoing PICC insertion who had both laboratory screening and post-PICC hemoglobin level. Two cohorts (A: 0-3 months; B: >3 months-18 years) were analyzed for procedural major/minor bleeding. RESULTS Of 1,441 consecutive children identified during a 3-year period, 832 patients (226 in cohort A, 606 in cohort B) fulfilled the inclusion criteria. Overall, 36% (300/832) of the patients had at least one abnormal laboratory result. Only 0.2% (3/1,441) of patients required conversion to a central venous line. In cohort A no major bleeding occurred; the minor bleeding frequency was 30% (68/226). Neither abnormal laboratory results nor correction of abnormal laboratory results was associated with minor bleeding complications. The positive and negative predictive values (PPV/NPV) of having abnormal laboratory screening were 0.22 and 0.68, respectively. In cohort B the major bleeding frequency was 1% (6/606) but no patient required any blood transfusion; minor bleeding occurred in 29% (174/606). Neither abnormal laboratory results nor correction of abnormal laboratory results was associated with minor bleeding complications. The PPV and NPV of abnormal laboratory screening results were 0.24 and 0.72, respectively. CONCLUSION Pre-procedural blood screening did not predict bleeding in hospitalized children without a known bleeding diathesis undergoing PICC insertion. The rarity of major bleeding complications and need for conversion to a central venous line did not support a need for laboratory screening.
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Affiliation(s)
- Joel Woodley-Cook
- Diagnostic Imaging, Image Guided Therapy, The Hospital for Sick Children, Toronto, Canada
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69
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Singh SA, Sharma S, Singh A, Singh AK, Sharma U, Bhadoria AS. The safety of ultrasound guided central venous cannulation in patients with liver disease. Saudi J Anaesth 2015; 9:155-60. [PMID: 25829903 PMCID: PMC4374220 DOI: 10.4103/1658-354x.152842] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Central venous cannulation (CVC) is frequently required during the management of patients with liver disease with deranged conventional coagulation parameters (CCP). Since CVC is known to be associated with vascular complications, it is standard practice to transfuse Fresh-Frozen Plasma or platelets to correct CCP. These CCP may not reflect true coagulopathy in liver disease. Additionally CVC when performed under ultrasound guidance (USG-CVC) in itself reduces the incidence of complications. Aim: To assess the safety of USG-CVC and to evaluate the incidence of complications among liver disease patients with coagulopathy. Setting and Design: An audit of all USG-CVCs was performed among adult patients with liver disease in a tertiary care center. Materials and Methods: Data was collected for all the adult patients (18-60 years) of either gender suffering from liver disease who had required USG-CVC. Univariate and multivariate regression analysis was done to identify possible risk factors for complications. Results: The mean age of the patients was 42.1 ± 11.6 years. Mean international normalized ratio was 2.17 ± 1.16 whereas median platelet count was 149.5 (range, 12-683) × 109/L. No major vascular or non-vascular complications were recorded in our patients. Overall incidence of minor vascular complications was 18.6%, of which 13% had significant ooze, 10.3% had hematoma formation and 4.7% had both hematoma and ooze. Arterial puncture and multiple attempts were independent risk factors for superficial hematoma formation whereas low platelet count and presence of ascites were independent risk factors for significant oozing. Conclusion: Ultrasound guidance -CVC in liver disease patients with deranged coagulation is a safe and highly successful modality.
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Affiliation(s)
- Shweta A Singh
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
| | - Sandeep Sharma
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
| | - Anshuman Singh
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
| | - Anil K Singh
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
| | - Utpal Sharma
- Department of Anesthesiology and Critical Care, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
| | - Ajeet Singh Bhadoria
- Department of Clinical Research, Institute of Liver and Biliary Science, Vasant Kunj, New Delhi, India
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70
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Beer KS, Silverstein DC. Controversies in the use of fresh frozen plasma in critically ill small animal patients. J Vet Emerg Crit Care (San Antonio) 2015; 25:101-6. [PMID: 25603692 DOI: 10.1111/vec.12280] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 09/15/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To review the literature supporting or discouraging the use of fresh frozen plasma (FFP) transfusion in critically ill patients. DATA SOURCES Human and animal publications were searched using PubMed without time limits and the following keywords were used: "fresh frozen plasma," "coagulopathy," "hypocoagulable state," "hypercoagulable states," and "critical illness." HUMAN DATA SYNTHESIS The commonly used tests of coagulation (eg, prothrombin time, activated partial thromboplastin time, international normalized ratio) are poorly predictive of clinical bleeding. FFP use in critically ill patients is unlikely to result in improved outcomes and may be associated with increased risks. VETERINARY DATA SYNTHESIS There is insufficient evidence to make definitive conclusions regarding the use of FFP in critically ill animals, but clinical studies are underway that may provide further data that clarify the optimal use of FFP in animals. CONCLUSIONS The use of FFP in critically ill patients remains controversial. In the absence of clinical bleeding or a risk for clinical bleeding associated with a planned procedure, treatment use of FFP is not recommended in human patients. There are insufficient data in critically ill animals to enable formulation of recommendations. Further research is warranted in dogs and cats to establish evidence-based guidelines.
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Affiliation(s)
- Kari Santoro Beer
- Department of Clinical Studies, University of Pennsylvania, Philadelphia, PA
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Abstract
Fibrinogen is a critical protein for hemostasis and clot formation. However, transfusion guidelines have variable recommendations for maintaining fibrinogen levels in bleeding patients. An increasing number of studies support the practice of fibrinogen replacement therapy for acquired coagulopathies, and additional studies are underway. Fibrinogen therapy can be administered with cryoprecipitate or fibrinogen concentrates, and clinical practice varies according to their availability and licensing status. Fibrinogen concentrate therapy has been studied in animal models and clinical trials and supports the critical role of fibrinogen repletion in bleeding patients. Point-of-care testing will have an important role in guiding fibrinogen replacement for hemostatic therapy in clinical settings such as cardiovascular surgery, postpartum hemorrhage, and trauma. Fibrinogen therapy is an important component of a multimodal strategy for the treatment of coagulopathic bleeding.
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72
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Gill R. Practical management of major blood loss. Anaesthesia 2014; 70 Suppl 1:54-7, e19-20. [DOI: 10.1111/anae.12915] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2014] [Indexed: 12/22/2022]
Affiliation(s)
- R. Gill
- Shackleton Department of Anaesthesia; University Hospital Southampton; Southampton UK
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73
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Goodnough LT, Shah N. The next chapter in patient blood management: real-time clinical decision support. Am J Clin Pathol 2014; 142:741-7. [PMID: 25389326 DOI: 10.1309/ajcp4w5ccfozujfu] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Blood transfusion was identified by the American Medical Association as one of the top five most frequently overused therapies. Utilization review has been required by accreditation agencies, but retrospective review has been ineffective due to labor-intense resources applied to only a sampling of transfusion events. Electronic medical records have allowed clinical decision support (CDS) to occur via a best practices alert at the critical decision point concurrently with physician order entry. METHODS We review emerging strategies for improving blood utilization. RESULTS Implementation of CDS at our institution decreased the percentage of transfusions in patients with a hemoglobin level of more than 8 g/dL from 60% to less than 30%. Annual RBC transfusions were reduced by 24%, despite concurrent increases in patient discharge volumes and case mix complexity. This resulted in acquisition costs savings (direct blood product purchase costs) of $6.4 million over 4 years. CONCLUSIONS We have been able to significantly reduce inappropriate blood transfusions and related costs through an educational initiative coupled with real-time CDS. In deriving increased value out of health care, CDS can be applied to a number of overuse measures in laboratory testing, radiology, and therapy such as antibiotics, as outlined by the American Board of Internal Medicine's Choosing Wisely campaign.
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Affiliation(s)
- Lawrence Tim Goodnough
- Department of Pathology, Stanford University, Stanford, CA
- Department of Medicine, Stanford University, Stanford, CA
| | - Neil Shah
- Department of Pathology, Stanford University, Stanford, CA
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74
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Soundar EP, Besandre R, Hartman SK, Teruya J, Hui SKR. Plasma is ineffective in correcting mildly elevated PT-INR in critically ill children: a retrospective observational study. J Intensive Care 2014; 2:64. [PMID: 25705420 PMCID: PMC4336132 DOI: 10.1186/s40560-014-0064-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 11/13/2014] [Indexed: 11/20/2022] Open
Abstract
Background Fresh frozen plasma transfusion is widely utilized in pediatric clinical practice to correct mild coagulopathy. Several studies on adult population have shown that transfusion of plasma cannot effectively correct mild coagulopathy when international normalized ratio (INR) is ≤1.5. Much controversy exists about the generalization of this finding for pediatric populations, especially since pediatric dosages often exceed those in adults. The aim of this study is to determine the prevalence of plasma transfusion with mild coagulopathy (INR ≤ 1.5) and its effectiveness in a pediatric setting. Methods In our tertiary referral hospital, we retrospectively reviewed the electronic medical records of all patients who received plasma (April to October 2011) for mildly elevated prothrombin time (PT)-INR levels (≤1.5) and had post-transfusion PT-INR measurements; patients who received intraoperative, ECMO, or plasma exchange-related plasma transfusions were excluded from this study. We abstracted demographic data and pre- and post coagulation test results for the patients included in our study. Results Among 468 plasma transfusions administered to 285 patients from April to June 2011, 60 plasma transfusions (12.8%) were given to patients with PT-INR ≤ 1.5 (range 1.3–1.5). Forty-one patients [median age 2.5 years (IQR, 0.14 to 13.75 years), median weight of 16.0 kg (IQR, 8.0 to 69.3 kg)] who received 41 single plasma transfusions [median dose 11 mL/Kg (IQR, 6–15)] had post-transfusion PT-INR measurements and were included in our study. There was no significant difference in their PT-INR values (p = 0.34) pre- and post-transfusion. Of our study, only 15.4% patients showed post-transfusion normalization [median change in PT-INR 0.15 (IQR, 0.1–0.2)] and were not different from the remaining 85% in age, plasma dose, and bleeding status. Conclusions The prevalence of plasma transfusion for correction of mildly elevated PT-INR levels in critically ill children is high (12.8%). Plasma transfusion showed no significant effect in correcting minor prolongation of PT-INR in pediatric patients regardless of age, volume of plasma transfused per kilogram (dosage), or bleeding status.
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Affiliation(s)
- Esther Paula Soundar
- Department of Pathology and Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Ronald Besandre
- Division of Transfusion Medicine and Coagulation, Texas Childrens' Hospital, 6621 Fannin Street, Suite WB 1100, Houston, TX 77030 USA
| | - Sarah Kate Hartman
- Division of Transfusion Medicine and Coagulation, Texas Childrens' Hospital, 6621 Fannin Street, Suite WB 1100, Houston, TX 77030 USA ; Department of Pathology and Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Jun Teruya
- Division of Transfusion Medicine and Coagulation, Texas Childrens' Hospital, 6621 Fannin Street, Suite WB 1100, Houston, TX 77030 USA ; Department of Pathology and Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
| | - Shiu-Ki Rocky Hui
- Division of Transfusion Medicine and Coagulation, Texas Childrens' Hospital, 6621 Fannin Street, Suite WB 1100, Houston, TX 77030 USA ; Department of Pathology and Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 USA
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Eltringham-Smith LJ, Lei X, Reheman A, Lambourne MD, Pryzdial EL, Ni H, Sheffield WP. The fibrinogen but not the Factor VIII content of transfused plasma determines its effectiveness at reducing bleeding in coagulopathic mice. Transfusion 2014; 55:1040-50. [DOI: 10.1111/trf.12931] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/23/2014] [Accepted: 09/26/2014] [Indexed: 01/19/2023]
Affiliation(s)
| | - Xi Lei
- Centre for Innovation; Canadian Blood Services; Hamilton Ontario Canada
- Toronto Ontario Canada
- Vancouver British Columbia Canada
- Department of Laboratory Medicine; University of Toronto; Keenan Research Centre for Biomedical Science of St Michael's Hospital; Toronto Ontario Canada
| | - Adili Reheman
- Department of Laboratory Medicine; University of Toronto; Keenan Research Centre for Biomedical Science of St Michael's Hospital; Toronto Ontario Canada
| | - Melissa D. Lambourne
- Centre for Innovation; Canadian Blood Services; Hamilton Ontario Canada
- Toronto Ontario Canada
- Vancouver British Columbia Canada
| | - Edward L. Pryzdial
- Centre for Innovation; Canadian Blood Services; Hamilton Ontario Canada
- Toronto Ontario Canada
- Vancouver British Columbia Canada
- Centre for Blood Research; University of British Columbia; Vancouver British Columbia Canada
| | - Heyu Ni
- Centre for Innovation; Canadian Blood Services; Hamilton Ontario Canada
- Toronto Ontario Canada
- Vancouver British Columbia Canada
- Department of Laboratory Medicine; University of Toronto; Keenan Research Centre for Biomedical Science of St Michael's Hospital; Toronto Ontario Canada
| | - William P. Sheffield
- Department of Pathology and Molecular Medicine; McMaster University; Hamilton Ontario Canada
- Centre for Innovation; Canadian Blood Services; Hamilton Ontario Canada
- Toronto Ontario Canada
- Vancouver British Columbia Canada
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76
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Runkel S, Hitzler WE, Hellstern P. The impact of whole blood processing and freezing conditions on the quality of therapeutic plasma prepared from whole blood. Transfusion 2014; 55:796-804. [DOI: 10.1111/trf.12914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 09/16/2014] [Accepted: 09/17/2014] [Indexed: 01/25/2023]
Affiliation(s)
- Stefan Runkel
- Transfusion Center; University Medical Center of the Johannes Gutenberg University Mainz; Mainz Germany
| | - Walter E. Hitzler
- Transfusion Center; University Medical Center of the Johannes Gutenberg University Mainz; Mainz Germany
| | - Peter Hellstern
- Institute of Hemostaseology and Transfusion Medicine; Academic City Hospital; Ludwigshafen Germany
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77
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Miao X, Liu J, Zhao M, Cui Y, Feng Z, Zhao J, Long C, Li S, Yan F, Wang X, Hu S. The influence of cardiopulmonary bypass priming without FFP on postoperative coagulation and recovery in pediatric patients with cyanotic congenital heart disease. Eur J Pediatr 2014; 173:1437-43. [PMID: 24863631 DOI: 10.1007/s00431-014-2335-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 05/04/2014] [Accepted: 05/06/2014] [Indexed: 11/28/2022]
Abstract
UNLABELLED Transfusion guidelines have been produced for the evidence-based use of fresh frozen plasma (FFP). However, the inappropriate use of FFP is still a worldwide problem, especially in the prophylactic settings. In the present study, 100 cyanotic pediatric patients (age 6 months to 3 years) undergoing cardiac surgery with cardiopulmonary bypass (CPB) were randomized to receive either 10-20 ml/kg FFP (FFP group, n = 50) or 10-20 ml/kg 4 % succinylated gelatin (Gelofusine, GEL group, n = 50) in the priming solution. Rapid thromboelastography (r-TEG) was measured before skin incision and 15 min after heparin neutralization. Postoperative renal and hepatic function, mediastinal chest tube drainage, transfusion requirements, and recovery time were observed. The relationships between hematologic and demographic data and postoperative bleeding volume were also analyzed. The results showed that there were significantly elevated levels of fibrinogen (r-TEG parameters: fibrinogen contribution to maximal amplitude (MAf) and fibrinogen level (FLEV)) in the FFP group compared to the GEL group. The postoperative blood loss, total transfusion requirements, and recovery time were not significantly different between the two groups, indicating that there were no obvious clinical benefits of using FFP in the priming. The maximal amplitude (MA) of r-TEG measured after heparin neutralization was correlated with the 6-h postoperative bleeding volume. In addition, preoperative fibrinogen level rather than FFP priming was an independent predictor of postoperative blood loss. CONCLUSION Prophylactic use of FFP in the priming solution does not have obvious clinical benefits in cyanotic congenital heart disease (CCHD) patients. Gelofusine, an artificial colloid, is a safe and effective substitute of FFP in the priming solution. Furthermore, r-TEG can be used as a "real-time" assessment tool to evaluate postoperative bleeding and guide transfusion after cardiac surgery in pediatric patients.
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Affiliation(s)
- Xiaolei Miao
- Department of Cardiopulmonary Bypass, Cardiovascular Institute, Fuwai Hospital and National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, No. 167, Bei Li Shi Road, Xi Cheng, 100037, Beijing, China,
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78
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Only AJ, DeChristopher PJ, Iqal O, Fareed J. Restoration of Normal Prothrombin Time/International Normalized Ratio With Fresh Frozen Plasma in Hypocoagulable Patients. Clin Appl Thromb Hemost 2014; 22:85-91. [PMID: 25294634 DOI: 10.1177/1076029614550819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Fresh frozen plasma (FFP) is an effective reversal agent for hypocoagulable patients. Its proven efficacy continues to prompt its usage as both a prophylactic and a therapeutic therapy. Although published guidelines encouraging the appropriate administration of FFP exist, overutilization continues. The purpose of these ex vivo studies was to determine the effects of succeeding volumes of FFP supplementation on hypocoagulable plasma prothrombin time/international normalized ratio (PT/INR). By analyzing the decline in PT/INR with varying volumes of FFP, a minimal required volume of FFP could be identified representing the optimal volume to administer while still providing therapeutic effect. A total of 497 plasma samples were screened for elevated PT/INR values and 50 samples were selected for inclusion in this experiment. The initial PTs/INRs ranged from 12.5 to 43.4 seconds/1.42 to 4.91. Subsequent declines in PT/INR values were analyzed following addition of 50, 100, and 150 µL of FFP to a fixed volume of 250 µL of plasma (26.4 ± 5.318 seconds/2.99 ± 0.603, 13.3 ± 1.077 seconds/1.51 ± 0.122, 11.2 ± 0.712 seconds/1.27 ± 0.081, and 10.3 ± 0.533 seconds/1.16 ± 0.06, respectively). A nonlinear relationship between decline in INR values and percentage of FFP supplementation was demonstrated. The greatest effect on INR was obtained after supplementation with 50 µL (49%). Doubling and tripling the volume of FFP lead to significantly lower declines in INR (16% and 8%, respectively). Analysis of variance indicated a statistical significance with subsequent volume supplementation of FFP, but marginal clinical benefits exist between the PTs/INRs obtainable with increased FFP volume administration.
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Affiliation(s)
- Arthur J Only
- Department of Pathology, Loyola University Chicago, Maywood, IL, USA
| | | | - Omer Iqal
- Department of Pathology, Loyola University Chicago, Maywood, IL, USA
| | - Jawed Fareed
- Department of Pathology, Loyola University Chicago, Maywood, IL, USA
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Müller MCA, de Haan RJ, Vroom MB, Juffermans NP. Evaluation of a multi-center randomised clinical trial on prophylactic transfusion of fresh frozen plasma: implications for future trials. Transfus Med 2014; 24:292-6. [DOI: 10.1111/tme.12151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 07/23/2014] [Accepted: 08/11/2014] [Indexed: 11/30/2022]
Affiliation(s)
- M. C. A. Müller
- Department of Intensive Care Medicine; Academic Medical Center; Amsterdam the Netherlands
| | - R. J. de Haan
- Clinical Research Unit; Academic Medical Center; Amsterdam the Netherlands
| | - M. B. Vroom
- Department of Intensive Care Medicine; Academic Medical Center; Amsterdam the Netherlands
| | - N. P. Juffermans
- Department of Intensive Care Medicine; Academic Medical Center; Amsterdam the Netherlands
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Raval JS, Waters JH, Triulzi DJ, Yazer MH. Complications following an unnecessary peri-operative plasma transfusion and literature review. Asian J Transfus Sci 2014; 8:139-41. [PMID: 25161359 PMCID: PMC4140061 DOI: 10.4103/0973-6247.137458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Plasma is used to correct coagulopathies, but not all coagulation abnormalities are clinically significant enough to require correction before an invasive procedure. We report an 82-year-old female who, in response to a mildly prolonged INR of unknown etiology, was unnecessarily transfused with plasma in advance of elective surgery. The patient suffered a moderately severe transfusion reaction, including hives and voice hoarseness, which caused a 4-week delay in her surgery. This delay and adverse reaction could have been avoided had the principles of evidence based plasma therapy, which we herein review, been followed and if the etiology of the mildly elevated INR been investigated before the day of her surgery.
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Affiliation(s)
- Jay S Raval
- Department of Pathology, University of Pittsburgh Medical Center, Magee Women's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA ; The Institute for Transfusion Medicine, Magee Women's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan H Waters
- Department of Anesthesiology, Magee Women's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Darrell J Triulzi
- Department of Pathology, University of Pittsburgh Medical Center, Magee Women's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA ; The Institute for Transfusion Medicine, Magee Women's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh Medical Center, Magee Women's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA ; The Institute for Transfusion Medicine, Magee Women's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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81
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Banerjee D, Hussain R, Mazer J, Carino G. A prophylactic fresh frozen plasma transfusion leads to a possible case of transfusion-related acute lung injury. BMJ Case Rep 2014; 2014:bcr-2014-204101. [PMID: 25053669 DOI: 10.1136/bcr-2014-204101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 39-year-old man with cholangiocarcinoma presented with fever and abdominal pain. He was hypotensive, jaundiced and had right upper quadrant tenderness. Laboratory testing showed a leucocytosis, elevated liver function tests, total bilirubin and International Normalised Ratio (INR). Given the concern for cholangitis, the patient was given antibiotics and three units of fresh frozen plasma (FFP) before biliary drain placement. After drain placement, and within 3 h of receiving blood products, the patient became tachypnoeic and hypoxic with a chest X-ray revealing new bilateral airspace disease. The rapid development of respiratory distress was determined to most likely be transfusion-related acute lung injury (TRALI). He rapidly progressed to intubation and required 100% FiO2, high positive-end expiratory pressure (PEEP) and intermittent-prone ventilation for 48 h but eventually recovered and was extubated. TRALI is an under-recognised aetiology for respiratory distress in the critically ill. Adopting a conservative transfusion strategy may prevent TRALI.
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Affiliation(s)
- Debasree Banerjee
- Division of Pulmonary, Critical Care and Sleep Medicine, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Rashid Hussain
- Division of Pulmonary, Critical Care and Sleep Medicine, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Jeffrey Mazer
- Division of Pulmonary, Critical Care and Sleep Medicine, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Gerardo Carino
- Division of Pulmonary, Critical Care and Sleep Medicine, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
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Goobie SM, Haas T. Bleeding management for pediatric craniotomies and craniofacial surgery. Paediatr Anaesth 2014; 24:678-89. [PMID: 24815192 DOI: 10.1111/pan.12416] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2014] [Indexed: 11/27/2022]
Abstract
Pediatric patients when undergoing craniotomies and craniofacial surgery may potentially have significant blood loss. The amount and extent will be dictated by the nature of the surgical procedure, the proximity to major blood vessels, and the age, and weight of the patient. The goals should be to maintain hemodynamic stability and oxygen carrying capacity and to prevent and treat hyperfibrinolysis and dilutional coagulopathy. Over transfusion and transfusion-related side effects should be minimized. This article will highlight the pertinent considerations for managing massive blood loss in pediatric patients undergoing craniotomies and craniofacial surgery. North American and European guidelines for intraoperative administration of fluid and blood products will be discussed.
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Affiliation(s)
- Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
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83
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Motta M, Del Vecchio A, Perrone B, Ghirardello S, Radicioni M. Fresh frozen plasma use in the NICU: a prospective, observational, multicentred study. Arch Dis Child Fetal Neonatal Ed 2014; 99:F303-8. [PMID: 24646616 DOI: 10.1136/archdischild-2013-304747] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To examine the use of fresh frozen plasma (FFP) in Italian neonatal intensive care units (NICUs); specifically to quantify compliance with guideline recommendations and to evaluate the relationship between coagulation tests and subsequent bleeding episodes. DESIGN Prospective, observational study. SETTING Seventeen Italian NICUs. PATIENTS AND METHODS Over a period of 12 months, for all neonates that received FFP we recorded specific characteristics, pretransfusion and post-transfusion laboratory test of haemostasis, and details of all haemorrhagic events. RESULTS Among 3506 NICU admissions, 290 (8.2%) received one or more FFP transfusions during their hospital stay. Of these, 37% received FFP because of active bleeding and 63% received FFP prophylactically with the intention of preventing haemorrhage. A total of 609 FFP transfusions were administered (mean 2.1/transfused patient-range 1-25). Using previously agreed upon criteria, we judged that 60% of the 609 FFP transfusions were not compliant with guideline recommendations. By logistic regression, abnormalities in the prothrombin time, activated partial thromboplastin time, fibrinogen and platelet count were not independently associated with bleeding episodes. CONCLUSIONS FFP transfusion is a relatively frequent intervention in the NICU. In the present analysis, we found a remarkably high proportion of FFP transfusions given to non-bleeding neonates for indications not compliant with guideline recommendations. Platelet counts and coagulation studies were poor predictors of clinical bleeding.
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84
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Müller MC, Arbous MS, Spoelstra-de Man AM, Vink R, Karakus A, Straat M, Binnekade JM, de Jonge E, Vroom MB, Juffermans NP. Transfusion of fresh-frozen plasma in critically ill patients with a coagulopathy before invasive procedures: a randomized clinical trial (CME). Transfusion 2014; 55:26-35; quiz 25. [PMID: 24912653 DOI: 10.1111/trf.12750] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 05/03/2014] [Accepted: 05/04/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Prophylactic use of fresh-frozen plasma (FFP) is common practice in patients with a coagulopathy undergoing an invasive procedure. Evidence that FFP prevents bleeding is lacking, while risks of transfusion-related morbidity after FFP have been well demonstrated. We aimed to assess whether omitting prophylactic FFP transfusion in nonbleeding critically ill patients with a coagulopathy who undergo an intervention is noninferior to a prophylactic transfusion of FFP. STUDY DESIGN AND METHODS A multicenter randomized open-label trial with blinded endpoint evaluation was performed in critically ill patients with a prolonged international normalized ratio (INR; 1.5-3.0). Patients undergoing placement of a central venous catheter, percutaneous tracheostomy, chest tube, or abscess drainage were eligible. Patients with clinically overt bleeding, thrombocytopenia, or therapeutic use of anticoagulants were excluded. Patients were randomly assigned to omitting or administering a prophylactic transfusion of FFP (12 mL/kg). Outcomes were occurrence of postprocedural bleeding complications, INR correction, and occurrence of lung injury. RESULTS Due to slow inclusion, the trial was stopped before the predefined target enrollment was reached. Eighty-one patients were randomly assigned, 40 to FFP and 41 to no FFP transfusion. Incidence of bleeding did not differ between groups, with a total of one major and 13 minor bleedings (p = 0.08 for noninferiority). FFP transfusion resulted in a reduction of INR to less than 1.5 in 54% of transfused patients. No differences in lung injury scores were observed. CONCLUSION In critically ill patients undergoing an invasive procedure, no difference in bleeding complications was found regardless whether FFP was prophylactically administered or not.
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Affiliation(s)
- Marcella C Müller
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands
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85
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Thorell SE, Nash MJ, Thachil J. Clinical implications of clotting screens. Int J Lab Hematol 2014; 37:8-13. [DOI: 10.1111/ijlh.12206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 02/10/2014] [Indexed: 11/29/2022]
Affiliation(s)
- S. E. Thorell
- School of Medicine; University of Manchester; Manchester UK
| | - M. J. Nash
- Department of Haematology; Manchester Royal Infirmary; Manchester UK
| | - J. Thachil
- Department of Haematology; Manchester Royal Infirmary; Manchester UK
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86
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Durand M, Rossi-Blancher M, Poquet C. [Blood transfusion via the cardiopulmonary bypass circuit: the anesthesiologist point of view]. ACTA ACUST UNITED AC 2014; 33 Suppl 1:S10-3. [PMID: 24613767 DOI: 10.1016/j.annfar.2014.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 01/29/2014] [Indexed: 10/25/2022]
Abstract
Cardiac surgery frequently requires blood transfusion. The use of transfusion should be restricted due to side effects. Blood transfusion via the cardiopulmonary bypass (CPB) circuit is easy and allows a fast transfusion. The administration of packed red cells is relatively frequent because of the CPB-induced hemodilution and of the higher rate of postoperative complications when the haematocrit during CPB decreases below 20%. This transfusion of packed red cells does not seem to be associated with complications during CPB. Platelet transfusion during bypass is illogical because of the destruction of platelets during CPB and must be avoided. Fresh frozen plasma transfusion during CPB is seldom indicated but is possible. It could reverse heparin resistance.
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Affiliation(s)
- M Durand
- Département d'anesthésie-réanimation II, pole d'anesthésie-réanimation, hôpital Michallon, CHU de Grenoble, BP 217, CS10217, 38043 Grenoble cedex, France.
| | - M Rossi-Blancher
- Département d'anesthésie-réanimation II, pole d'anesthésie-réanimation, hôpital Michallon, CHU de Grenoble, BP 217, CS10217, 38043 Grenoble cedex, France
| | - C Poquet
- Département d'anesthésie-réanimation II, pole d'anesthésie-réanimation, hôpital Michallon, CHU de Grenoble, BP 217, CS10217, 38043 Grenoble cedex, France
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87
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Abstract
The liver plays a key role in both protein biosynthesis and lipid metabolism. As a result, hepatic synthetic dysfunction can have adverse effects on both cellular and soluble components of blood. Anemia may occur due to the hemolysis of acanthocytes (spur cells), which is ultimately due to abnormal lipid composition of the red blood cell membrane. Thrombocytopenia may result from several different mechanisms. Cytopenias also may be a consequence of hypersplenism. The liver is the primary site for synthesis of most procoagulant and anticoagulant proteins. The coagulopathy of liver disease is therefore complex. Early in the course of liver disease, thrombocytopenia and a coagulopathy associated with a prothrombotic state are not uncommon, whereas with more advanced disease pancytopenia and coagulopathy associated with hemorrhage become manifest. Fresh frozen plasma and adjuncts to hemostasis may be used as temporizing measures in bleeding patients. However, definitive management of many of the defects due to fulminant hepatic failure requires liver transplantation.
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Affiliation(s)
- Peter W Marks
- Center for Biologics Evaluation and Research, United States Food and Drug Administration, Rockville, MD 20852, USA.
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88
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89
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Garraud O, Chavarin P, Boussoulade F, Morata P, Rochette-Eribon S, Acquart S, Fabrigli P, Argaud C, Bost V, Cognasse F. [The different types of therapeutic plasma are equivalent?]. Transfus Clin Biol 2014; 21:31-6. [PMID: 24560485 DOI: 10.1016/j.tracli.2014.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 01/09/2014] [Indexed: 11/16/2022]
Abstract
In France, three varieties of therapeutic plasma are being processed, distributed and delivered, currently; however, many more varieties are in use worldwide, which go by the property of labile blood component or plasma derived medicines. For one type of component (one given name), several devices and bags and so on are used to concur to its process, which makes that one type of therapeutic plasma may significantly differ from one production setting to one other. This may affect (more or less) the component properties as well as the possibly reported adverse events. This review aims thus, firstly at stressing on the difficulty in comparing data obtained in different contexts, and secondly at making the point on future directions to process therapeutic plasma.
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Affiliation(s)
- O Garraud
- Établissement français du sang Auvergne-Loire, 42023 Saint-Étienne, France; Faculté de médecine, université de Lyon, 42023 Saint-Étienne, France.
| | - P Chavarin
- Établissement français du sang Auvergne-Loire, 42023 Saint-Étienne, France
| | - F Boussoulade
- Établissement français du sang Auvergne-Loire, 42023 Saint-Étienne, France
| | - P Morata
- Établissement français du sang Auvergne-Loire, 42023 Saint-Étienne, France
| | - S Rochette-Eribon
- Établissement français du sang Auvergne-Loire, 42023 Saint-Étienne, France
| | - S Acquart
- Établissement français du sang Auvergne-Loire, 42023 Saint-Étienne, France
| | - P Fabrigli
- Établissement français du sang Auvergne-Loire, 42023 Saint-Étienne, France
| | - C Argaud
- Établissement français du sang Auvergne-Loire, 42023 Saint-Étienne, France
| | - V Bost
- Établissement français du sang Auvergne-Loire, 42023 Saint-Étienne, France; Faculté de médecine, université de Lyon, 42023 Saint-Étienne, France
| | - F Cognasse
- Établissement français du sang Auvergne-Loire, 42023 Saint-Étienne, France; Faculté de médecine, université de Lyon, 42023 Saint-Étienne, France
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90
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Abstract
PURPOSE OF REVIEW This review summarizes the current evidence base for commonly transfused blood components with a particular focus on the nonacutely bleeding patient. RECENT FINDINGS There remains little definitive evidence to guide transfusion practices in the critically ill. The most rigorous evidence to guide red blood cell (RBC) transfusion practice is derived from the Transfusion in Critical Care Trial (TRICC Trial) that was published in 1999. Specific subgroups of patients may be at particular risk of the adverse effects of anemia, and require further study. There are no randomized controlled trials addressing clinically important outcomes evaluating frozen plasma, platelet thresholds, or impaired platelet activity in the critically ill. SUMMARY As all blood components have some level of risk, the general approach to transfusion should be one of minimization. For the nonacutely bleeding critically ill patient, a RBC transfusion trigger of 70 g/l is clinically acceptable. For patients at potentially higher risk of adverse effects related to anemia such as those with septic shock, severe and/or acute ischemic heart disease, or brain injury, a higher threshold (80-90 g/l) may be considered. There is insufficient evidence to recommend specific thresholds for transfusion of frozen plasma or platelets in the critically ill.
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91
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Shander A, Michelson EA, Sarani B, Flaherty ML, Shulman IA. Use of plasma in the management of central nervous system bleeding: evidence-based consensus recommendations. Adv Ther 2014; 31:66-90. [PMID: 24338742 DOI: 10.1007/s12325-013-0083-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Central nervous system (CNS) hemorrhage is a potentially life-threatening condition, especially in patients with acquired coagulopathy. In this setting, treatment of CNS bleeding includes hemostatic therapy to replenish coagulation factors. There is currently a debate over the hemostatic efficacy of plasma in many clinical settings, alongside increasing concern about transfusion-associated adverse events. Despite these concerns, plasma is widely used. Moreover, plasma transfusion practice is variable and there is currently no uniform approach to treatment of traumatic, surgical or spontaneous CNS hemorrhage. This study addresses the need for guidance on the indications and potential risks of plasma transfusion in these settings. An Expert Consensus Panel was convened to develop recommendations guiding the use of plasma to treat bleeding and/or coagulopathy associated with CNS hemorrhage. The panel did not advise on the best treatment available but rather proposed recommendations to be used in the formulation of local procedures to support emergency physicians in their decision-making process. METHODS Evidence was systematically gathered from the literature and rated using methods established by the Scottish Intercollegiate Guidelines Network. The evidence was used to develop graded consensus recommendations, which are presented along with the evidence-based rationale for each in this report. RESULTS Sixty-five articles were identified covering both vitamin K antagonist-anticoagulation reversal and treatment of bleeding/coagulopathy in non-anticoagulated patients. Recommendations were then developed in four clinical scenarios within each area, and agreed on unanimously by all members of the panel. CONCLUSION The Panel considered plasma to be reasonable therapy for CNS hemorrhage requiring urgent correction of coagulopathy, although physicians should be prepared for potential cardiopulmonary complications, and evidence suggests that alternative therapies have superior risk-benefit profiles. Plasma could not be recommended in the absence of hemorrhage or coagulopathy. Consideration of the absolute risks and benefits of plasma therapy before transfusion is imperative.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, Englewood, NJ, USA
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92
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Abstract
Both coagulopathy and abnormal thrombosis can complicate the anesthetic and surgical management of neonatal patients; however, the patterns of bleeding and thrombosis in neonates differ from those in adults or older children. Severe coagulopathic bleeding most commonly occurs during heart surgery and almost certainly contributes to morbidity and mortality in this population. Such severe bleeding is rare during other surgery; the exception is babies presenting to the operating room with established coagulopathy secondary to severe sepsis. Alternatively, pathological thrombosis will mainly occur in association with indwelling vascular access devices or surgically created vascular shunts. There are important differences between the coagulation system in neonates and older patients. The implication of this is that therapies established in other patient groups will not be optimal for neonates without adaptation. While evidence from high-quality clinical trials is rarely available, an understanding of how coagulation in neonates differs can help to guide practice. This review will discuss important differences between the coagulation system of neonates and older patients and how these relate to newer models of coagulation. The emphasis will be on issues likely to impact on perioperative care. In particular, the management of severe bleeding, the manipulation of coagulation during heart surgery, and the management of coagulopathy in septic neonates will be discussed in detail.
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Affiliation(s)
- Philip D Arnold
- Jackson Rees Department of Paediatric Anaesthesia, Alder Hey Children's Hospital NHS Trust, Liverpool, UK; University of Liverpool, Liverpool, UK
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93
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Kume K, M. Tsutsumi Y, Soga T, Sakai Y, Kambe N, Kawanishi R, Hamaguchi E, Kawahara T, Kasai A, Nakaji Y, T. Horikawa Y, Nakayama S, Kaji T, Irahara M, Tanaka K. A case of placenta percreta with massive hemorrhage during cesarean section. THE JOURNAL OF MEDICAL INVESTIGATION 2014; 61:208-12. [DOI: 10.2152/jmi.61.208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Yasuo M. Tsutsumi
- Department of Anesthesiology, Institute of Health Bioscience, the University of Tokushima Graduate School
| | - Tomohiro Soga
- Department of Anesthesiology, Institute of Health Bioscience, the University of Tokushima Graduate School
| | - Yoko Sakai
- Department of Anesthesiology, Tokushima University Hospital
| | - Noriko Kambe
- Department of Anesthesiology, Institute of Health Bioscience, the University of Tokushima Graduate School
| | | | - Eisuke Hamaguchi
- Department of Anesthesiology, Institute of Health Bioscience, the University of Tokushima Graduate School
| | | | - Asuka Kasai
- Department of Anesthesiology, Tokushima University Hospital
| | - Yoshimi Nakaji
- Department of Anesthesiology, Tokushima University Hospital
| | - Yousuke T. Horikawa
- Department of Anesthesiology, Institute of Health Bioscience, the University of Tokushima Graduate School
| | - Souichiro Nakayama
- Department of Obstetrics and Gynecology, Institute of Health Bioscience, the University of Tokushima Graduate School
| | - Takashi Kaji
- Department of Obstetrics and Gynecology, Institute of Health Bioscience, the University of Tokushima Graduate School
| | - Minoru Irahara
- Department of Obstetrics and Gynecology, Institute of Health Bioscience, the University of Tokushima Graduate School
| | - Katsuya Tanaka
- Department of Anesthesiology, Institute of Health Bioscience, the University of Tokushima Graduate School
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94
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Brennan IM, Faintuch S, Ahmed M. Preparation for Percutaneous Ablation Procedures. Tech Vasc Interv Radiol 2013; 16:209-18. [DOI: 10.1053/j.tvir.2013.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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95
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Quality of frozen transfusable plasma prepared from whole blood donations in Canada: An update. Transfus Apher Sci 2013; 49:440-6. [DOI: 10.1016/j.transci.2013.06.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 06/17/2013] [Indexed: 11/22/2022]
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96
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Kleinman S, Busch MP, Murphy EL, Shan H, Ness P, Glynn SA. The National Heart, Lung, and Blood Institute Recipient Epidemiology and Donor Evaluation Study (REDS-III): a research program striving to improve blood donor and transfusion recipient outcomes. Transfusion 2013; 54:942-55. [PMID: 24188564 DOI: 10.1111/trf.12468] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/11/2013] [Accepted: 09/11/2013] [Indexed: 12/29/2022]
Abstract
BACKGROUND The Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) is a 7-year multicenter transfusion safety research initiative launched in 2011 by the National Heart, Lung, and Blood Institute. STUDY DESIGN AND METHODS The domestic component involves four blood centers, 12 hospitals, a data coordinating center, and a central laboratory. The international component consists of distinct programs in Brazil, China, and South Africa, which involve US and in-country investigators. RESULTS REDS-III is using two major methods to address key research priorities in blood banking and transfusion medicine. First, there will be numerous analyses of large "core" databases; the international programs have each constructed a donor and donation database while the domestic program has established a detailed research database that links data from blood donors and their donations, the components made from these donations, and data extracts from the electronic medical records of the recipients of these components. Second, there are more than 25 focused research protocols involving transfusion recipients, blood donors, or both that either are in progress or are scheduled to begin within the next 3 years. Areas of study include transfusion epidemiology and blood utilization, transfusion outcomes, noninfectious transfusion risks, human immunodeficiency virus-related safety issues (particularly in the international programs), emerging infectious agents, blood component quality, donor health and safety, and other donor issues. CONCLUSIONS It is intended that REDS-III serve as an impetus for more widespread recipient and linked donor-recipient research in the United States as well as to help assure a safe and available blood supply in the United States and in international locations.
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Affiliation(s)
- Steven Kleinman
- Department of Pathology, University of British Columbia, Victoria, British Columbia, Canada
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97
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Puetz J. Fresh frozen plasma: the most commonly prescribed hemostatic agent. J Thromb Haemost 2013; 11:1794-9. [PMID: 23848285 DOI: 10.1111/jth.12351] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Indexed: 12/20/2022]
Abstract
Although fresh frozen plasma (FFP) is one of the most commonly prescribed therapies in clinical practice throughout the world today, there is little medical evidence available supporting its use. Recent guidelines have called for limiting FFP transfusions. Despite this, FFP use does not seem to be decreasing. The reasons for this are likely to be multifactorial, and may be based on ideas regarding medical practices dating back to Galen and Hippocrates. A review of the history of the development of FFP may shed some light on current clinical practice and guide the direction of future investigations and therapies.
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Affiliation(s)
- J Puetz
- Clinical Professor of Pediatrics, Saint Louis University, St Louis, MO, USA
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98
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Doussau A, Perez P, Puntous M, Calderon J, Jeanne M, Germain C, Rozec B, Rondeau V, Chêne G, Ouattara A, Janvier G. Fresh-frozen plasma transfusion did not reduce 30-day mortality in patients undergoing cardiopulmonary bypass cardiac surgery with excessive bleeding: the PLASMACARD multicenter cohort study. Transfusion 2013; 54:1114-24. [PMID: 24117772 DOI: 10.1111/trf.12422] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 07/03/2013] [Accepted: 07/04/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND During on-pump cardiac surgery, hemorrhagic complications occur frequently. Fresh-frozen plasma (FFP) is widely transfused to provide coagulation factors. Yet, no randomized clinical trial has demonstrated its benefits on mortality. We assessed the relationship between therapeutic transfusion of FFP and 30-day mortality in cardiac surgery patients suffering from excessive bleeding in a prospective cohort study. STUDY DESIGN AND METHODS Adult patients who underwent on-pump cardiac surgery and experienced excessive bleeding during the 48-hour perioperative period were recruited from 15 French centers between February 2004 and January 2006. Patients who received a preventive FFP transfusion were excluded. The association between FFP transfusion and all cause 30-day mortality was estimated using a Cox proportional hazards model, adjusted for confounding. A propensity score (PS) sensitivity analysis was also performed. RESULTS Among 967 patients included in this study, 58.1% received FFP. The median dose was 11.3 mL/kg (interquartile range, 7.6-19.5). The cumulative 30-day mortality rate was 11.3% (95% confidence interval [CI], 9.5-13.5). FFP transfusion was associated with a higher 30-day mortality (hazard ratio [HR], 3.2; 95% CI, 1.7-6.1) in univariate analysis; however, after adjusting for prognostic factors, there was no longer any association (HR, 1.5; 95% CI, 0.8-3.0, p = 0.20). The results of the PS analysis were consistent with the adjusted analysis. CONCLUSION Among on-pump cardiac surgery patients experiencing excessive perioperative bleeding, there is no evidence of a beneficial impact of FFP transfusion on mortality.
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Affiliation(s)
- Adélaïde Doussau
- Pole de Sante Publique et CIC-EC7, Unité de Soutien Méthodologique à la Recherche Clinique et Épidémiologique, CHU de Bordeaux, Bordeaux, France; CIC-EC7 et Centre INSERM U897-Epidemiologie-Biostatistique, INSERM, Bordeaux, France; ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Université Bordeaux, Bordeaux, France
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99
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Abstract
This article reviews the use of transfusion medicine in veterinary medicine and discusses current research regarding donor screening and component therapy. Typing and crossmatching methodologies are discussed. Available components, potential uses, and controversies in treatment are also discussed.
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Affiliation(s)
- Beth Davidow
- Animal Critical Care and Emergency Services, 11536 Lake City Way Northeast, Seattle, WA 98125, USA.
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100
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Magee G, Peters C, Zbrozek A. Analysis of Inpatient Use of Fresh Frozen Plasma and Other Therapies and Associated Outcomes in Patients with Major Bleeds from Vitamin K Antagonism. Clin Ther 2013; 35:1432-43. [DOI: 10.1016/j.clinthera.2013.07.331] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 06/11/2013] [Accepted: 07/17/2013] [Indexed: 10/26/2022]
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