Massive transfusion as a risk factor for acute lung injury: Association or causation?

Lung Compliance and Outcomes in Patients With Acute Respiratory Distress Syndrome Receiving ECMO

BACKGROUND

Limited data are available regarding mechanical ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal membrane oxygenation (ECMO).

METHODS

A retrospective analysis of acute respiratory distress syndrome patients on ECMO was conducted in 9 hospitals in Korea. Data on ventilator settings (pre-ECMO and 0, 4, 24, and 48 hours after ECMO) were collected. Based on the effect of the duration and intensity of mechanical ventilator on outcomes, time-weighted average values were calculated for ventilator parameters.

RESULTS

The 56 patients included in the study had a mean age of 55.5 years. The hospital and 6-month mortality rates were 48.1% and 54.0%, respectively, with a median ECMO duration of 9.4 days. After initiation of ECMO, peak inspiratory pressure, above positive end-expiratory pressure, tidal volume, and respiration rate were reduced, while lung compliance did not change significantly. Before and during ECMO support, tidal volume and lung compliance were higher in 6-month survivors than in nonsurvivors. In Cox proportional models, both lung compliance (odds ratio, 0.961; 95% confidence interval, 0.928 to 0.995) and time-weighted average-lung compliance (odds ratio, 0.943; 95% confidence interval, 0.903 to 0.986) were significantly associated with 6-month mortality. Kaplan-Meier curves revealed that patients with higher lung compliance before ECMO had a longer survival time at the 6-month follow-up than did those with lower lung compliance.

CONCLUSIONS

Lung compliance, whether before or during ECMO, may be an important predictor of outcome in acute respiratory distress syndrome patients receiving ECMO. However, this result requires confirmation in larger clinical studies.

Blood product transfusions and reactions

Blood product transfusions are an essential component of the practice of emergency medicine. From acute traumatic hemorrhage to chronic blood loss necessitating transfusion for symptomatic anemia, familiarity with individual blood products and their indications for transfusion is an essential tool for every emergency physician (EP). Although the focus of this article is primarily on the transfusion of red blood cells, many of the concepts are applicable to the transfusion of all blood products. EPs must be fully familiar with both the individual blood components and the potential reactions and complications of these transfusions.

Use of tracheostomy in the PICU among patients requiring prolonged mechanical ventilation

PURPOSE

The purpose of the present study is to describe the use of tracheostomy, specifically frequency, timing (in relation to initiation of mechanical ventilation), and associated factors, in a large cohort of children admitted to North American pediatric intensive care units (PICUs) and requiring prolonged mechanical ventilation.

METHODS

This was a retrospective cohort study. De-identified data were obtained from the VPS(LLC) database, a multi-site, clinical PICU database. Admissions between 1 July 2009 and 30 June 2011 were enrolled in the study if the patient required mechanical ventilation for at least 72 h and did not have a tracheostomy tube at initiation of mechanical ventilation.

RESULTS

A total of 13,232 PICU admissions from 82 PICUs were analyzed in the study; of these, 872 (6.6 %) had a tracheostomy tube inserted after initiation of mechanical ventilation. The rate varied significantly (0-13.4 %, p < 0.001) among the 45 PICUs that had 100 or more admissions included in the study. The median time to insertion of a tracheostomy tube was 14.4 days (IQR 7.4-25.7), and it also varied significantly by unit (4.3-30.4 days, p < 0.001) among those that performed at least ten tracheostomies included in the study.

CONCLUSIONS

There is significant variation in both the frequency and time to tracheostomy between the studied PICUs for patients requiring prolonged mechanical ventilation; among those who received a tracheostomy, the majority did so after two or more weeks of mechanical ventilation. Future studies examining tracheostomy benefits, disadvantages, outcomes, and resource utilization of this patient subgroup are indicated.

Predictors of pulmonary failure following severe trauma: a trauma registry-based analysis

BACKGROUND

The incidence of pulmonary failure in trauma patients is considered to be influenced by several factors such as liver injury. We intended to assess the association of various potential predictors of pulmonary failure following thoracic trauma and liver injury.

METHODS

Records of 12,585 trauma patients documented in the TraumaRegister DGU® of the German Trauma Society were analyzed regarding the potential impact of concomitant liver injury on the incidence of pulmonary failure using uni- and multivariate analyses. Pulmonary failure was defined as pulmonary failure of ≥ 3 SOFA-score points for at least two days. Patients were subdivided according to their injury pattern into four groups: group 1: AIS thorax < 3; AIS liver < 3; group 2: AIS thorax ≥ 3; AIS liver < 3; group 3: AIS thorax < 3; AIS liver ≥ 3 and group 4: AIS thorax ≥ 3; AIS liver ≥ 3.

RESULTS

Overall, 2643 (21%) developed pulmonary failure, 12% (n= 642) in group 1, 26% (n= 697) in group 2, 16% (n= 30) in group 3, and 36% (n= 188) in group 4. Factors independently associated with pulmonary failure included relevant lung injury, pre-existing medical conditions (PMC), sex, transfusion of more than 10 units of packed red blood cells (PRBC), Glasgow Coma Scale (GCS) ≤ 8, and the ISS. However, liver injury was not associated with an increased risk of pulmonary failure following severe trauma in our setting.

CONCLUSIONS

Specific factors, but not liver injury, were associated with an increased risk of pulmonary failure following trauma. Trauma surgeons should be aware of these factors for optimized intensive care treatment.

Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: a multicenter, prospective, cohort study

INTRODUCTION

Contemporary information on mechanical ventilation (MV) use in emerging countries is limited. Moreover, most epidemiological studies on ventilatory support were carried out before significant developments, such as lung protective ventilation or broader application of non-invasive ventilation (NIV). We aimed to evaluate the clinical characteristics, outcomes and risk factors for hospital mortality and failure of NIV in patients requiring ventilatory support in Brazilian intensive care units (ICU).

METHODS

In a multicenter, prospective, cohort study, a total of 773 adult patients admitted to 45 ICUs over a two-month period requiring invasive ventilation or NIV for more than 24 hours were evaluated. Causes of ventilatory support, prior chronic health status and physiological data were assessed. Multivariate analysis was used to identifiy variables associated with hospital mortality and NIV failure.

RESULTS

Invasive MV and NIV were used as initial ventilatory support in 622 (80%) and 151 (20%) patients. Failure with subsequent intubation occurred in 54% of NIV patients. The main reasons for ventilatory support were pneumonia (27%), neurologic disorders (19%) and non-pulmonary sepsis (12%). ICU and hospital mortality rates were 34% and 42%. Using the Berlin definition, acute respiratory distress syndrome (ARDS) was diagnosed in 31% of the patients with a hospital mortality of 52%. In the multivariate analysis, age (odds ratio (OR), 1.03; 95% confidence interval (CI), 1.01 to 1.03), comorbidities (OR, 2.30; 95% CI, 1.28 to 3.17), associated organ failures (OR, 1.12; 95% CI, 1.05 to 1.20), moderate (OR, 1.92; 95% CI, 1.10 to 3.35) to severe ARDS (OR, 2.12; 95% CI, 1.01 to 4.41), cumulative fluid balance over the first 72 h of ICU (OR, 2.44; 95% CI, 1.39 to 4.28), higher lactate (OR, 1.78; 95% CI, 1.27 to 2.50), invasive MV (OR, 2.67; 95% CI, 1.32 to 5.39) and NIV failure (OR, 3.95; 95% CI, 1.74 to 8.99) were independently associated with hospital mortality. The predictors of NIV failure were the severity of associated organ dysfunctions (OR, 1.20; 95% CI, 1.05 to 1.34), ARDS (OR, 2.31; 95% CI, 1.10 to 4.82) and positive fluid balance (OR, 2.09; 95% CI, 1.02 to 4.30).

CONCLUSIONS

Current mortality of ventilated patients in Brazil is elevated. Implementation of judicious fluid therapy and a watchful use and monitoring of NIV patients are potential targets to improve outcomes in this setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01268410.

Effects of Liver Function on Ionized Hypocalcaemia following Rapid Blood Transfusion

OBJECTIVE: Hypocalcaemia detrimentally affects the cardiovascular system and massive transfusion-related hypocalcaemia is particularly severe in end-stage liver disease patients undergoing liver transplantation (LT). This study, therefore, compared the severity and duration of ionized hypocalcaemia between patients with normal and impaired liver function. METHODS: Patients ( n = 26 per group) were transfused at a rate of 10 ml/kg within 10 min with packed red blood cells (PRBCs) during LT (group LP) or spinal surgery (group SP), or were infused with 0.9% normal saline during spinal surgery (group SN). Serum levels of ionized calcium were assessed before (T0), just after (T1), and at 20 (T2) and 60 min (T3) after transfusion. RESULTS: Transfusion with PRBCs caused more severe ionized hypocalcaemia than 0.9% normal saline at T1. In contrast to the faster (20 min) normalization in group SP, ionized hypocalcaemia in group LP persisted at T3. Serum ionized calcium levels at T3 showed correlations with vital signs, blood glucose, serum potassium, base deficit and lactate. CONCLUSION: Rapid blood transfusion caused more severe and prolonged ionized hypocalcaemia in patients with liver dysfunction than in those with normal liver function.

Intensive care unit discharge to the ward with a tracheostomy cannula as a risk factor for mortality: a prospective, multicenter propensity analysis

OBJECTIVE

To analyze the impact of decannulation before intensive care unit discharge on ward survival in nonexperimental conditions.

DESIGN

Prospective, observational survey.

SETTING

Thirty-one intensive care units throughout Spain.

PATIENTS

All patients admitted from March 1, 2008 to May 31, 2008.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

At intensive care unit discharge, we recorded demographic variables, severity score, and intensive care unit treatments, with special attention to tracheostomy. After intensive care unit discharge, we recorded intensive care unit readmission and hospital survival.

STATISTICS

Multivariate analyses for ward mortality, with Cox proportional hazard ratio adjusted for propensity score for intensive care unit decannulation. We included 4,132 patients, 1,996 of whom needed mechanical ventilation. Of these, 260 (13%) were tracheostomized and 59 (23%) died in the intensive care unit. Of the 201 intensive care unit tracheostomized survivors, 60 were decannulated in the intensive care unit and 141 were discharged to the ward with cannulae in place. Variables associated with intensive care unit decannulation (non-neurologic disease [85% vs. 64%], vasoactive drugs [90% vs. 76%], parenteral nutrition [55% vs. 33%], acute renal failure [37% vs. 23%], and good prognosis at intensive care unit discharge [40% vs. 18%]) were included in a propensity score model for decannulation. Crude ward mortality was similar in decannulated and nondecannulated patients (22% vs. 23%); however, after adjustment for the propensity score and Sabadell Score, the presence of a tracheostomy cannula was not associated with any survival disadvantage with an odds ratio of 0.6 [0.3-1.2] (p=.1).

CONCLUSION

In our multicenter setting, intensive care unit discharge before decannulation is not a risk factor.

Blood transfusion during cardiac surgery is associated with inflammation and coagulation in the lung: a case control study

INTRODUCTION

Blood transfusion is associated with increased morbidity and mortality in cardiac surgery patients, but cause-and-effect relations remain unknown. We hypothesized that blood transfusion is associated with changes in pulmonary and systemic inflammation and coagulation occurring in patients who do not meet the clinical diagnosis of transfusion-related acute lung injury (TRALI).

METHODS

We performed a case control study in a mixed medical-surgical intensive care unit of a university hospital in the Netherlands. Cardiac surgery patients (n = 45) were grouped as follows: those who received no transfusion, those who received a restrictive transfusion (one two units of blood) or those who received multiple transfusions (at least five units of blood). Nondirected bronchoalveolar lavage fluid (BALF) and blood were obtained within 3 hours postoperatively. Normal distributed data were analyzed using analysis of variance and Dunnett's post hoc test. Nonparametric data were analyzed using the Kruskal-Wallis and Mann-Whitney U tests.

RESULTS

Restrictive transfusion increased BALF levels of interleukin (IL)-1β and D-dimer compared to nontransfused controls (P < 0.05 for all), and IL-1β levels were further enhanced by multiple transfusions (P < 0.01). BALF levels of IL-8, tumor necrosis factor α (TNFα) and thrombin-antithrombin complex (TATc) were increased after multiple transfusions (P < 0.01, P < 0.001 and P < 0.01, respectively) compared to nontransfused controls, but not after restrictive transfusions. Restrictive transfusions were associated with increased pulmonary levels of plasminogen activator inhibitor 1 compared to nontransfused controls with a further increase after multiple transfusions (P < 0.001). Concomitantly, levels of plasminogen activator activity (PAA%) were lower (P < 0.001), indicating impaired fibrinolysis. In the systemic compartment, transfusion was associated with a significant increase in levels of TNFα, TATc and PAA% (P < 0.05).

CONCLUSIONS

Transfusion during cardiac surgery is associated with activation of inflammation and coagulation in the pulmonary compartment of patients who do not meet TRALI criteria, an effect that was partly dose-dependent, suggesting transfusion as a mediator of acute lung injury. These pulmonary changes were accompanied by systemic derangement of coagulation.

Experimental extracorporeal membrane oxygenation reduces central venous pressure: an adjunct to control of venous hemorrhage?

Background: Venoarterial ECMO has been utilized in trauma patients to improve oxygenation, particularly in the setting of pulmonary contusions and ARDS. We hypothesized that venoarterial ECMO could reduce the central venous pressure in the trauma scenario, thus, alleviating major venous hemorrhage. Methods: Ten swine were cannulated for venoarterial ECMO. Central venous pressure, mean arterial pressure, portal vein pressure and portal vein flow were recorded at three different flow rates in both a hemodynamic normal state and a setting of increased central venous pressure and right ventricular load, mimicking acute lung injury. Results: Venoarterial ECMO reduced the central venous pressure (CVP sup) from 9.4±0.8 to 7.3±0.7 mmHg (p<0.01) and increased the mean arterial pressure from 103±8 to 119±10 mmHg (p<0.01) in the normal hemodynamic state. In the state of increased right ventricular load, the CVPsup declined from 14.3±0.4 to 11.0±0.7mmHg (p<0.01) and the mean arterial pressure (MAP) increased from 66±6 to 113 ±5 mmHg (p<0.01). Conclusion: Venoarterial ECMO reduces systemic venous pressure while maintaining or improving systemic perfusion in both a normal circulatory state and in the setting of increased right ventricular load associated with acute lung injury. ECMO may be a useful tool in reducing blood loss during major venous hemorrhage in both trauma and selected elective surgery.

Patterns of Acquired Bleeding Disorders in a Tertiary Care Hospital

Bleeding disorders constitute a large proportion of referrals to hematology departments. Worldwide, acquired causes of bleeding are commoner than inherited ones. To identify the spectrum of these disorders, we evaluated all referrals for bleeding encountered in this tertiary care centre over a one-year period. Of the total 1342 cases, 1040 (77.5%) had underlying exclusively acquired causes, whereas inherited causes constituted 302 cases (22.5%). Amongst acquired causes, disseminated intravascular coagulation was seen in 297 (28.6%), hepatic coagulopathy in 218 (20.9%), neurosurgical causes (intracranial bleeds) in 154 (14.8%), malignancy in 89 (8.6%), and miscellaneous multiple acquired causes including those due to anticoagulant drug overdose in 282 patients (27.1%). Referrals for isolated prolonged prothrombin time or thrombocytopenia were common, but were excluded from this study because not all presented with bleeding. Prompt laboratory work-up and precise identification of acquired causes of bleeding is the key to planning appropriate patient management including transfusion support.

Age of transfused blood: an independent predictor of mortality despite universal leukoreduction

BACKGROUND

The transfusion of relatively older stored blood has been associated with an increased risk of multiple organ failure, infection, and death. It remains unknown whether this phenomenon is mitigated by transfusion of leukoreduced red cell units. The purpose of this study was to evaluate the influence of stored blood age on mortality in injured patients who universally received leukoreduced blood.

METHODS

Trauma patients who received > or = 1 unit of blood during the first 24 hours after hospital arrival were selected for inclusion. Patients were stratified both according to total units and "old" units (> or = 14 days) versus "young" units (< 14 days) received in the initial 24 hours. Odds ratios and 95% confidence intervals (CIs) were calculated for the association between mortality and the age and amount of blood transfused, adjusted for age, sex, injury severity, injury mechanism, number of units transfused, and length of stay.

RESULTS

Over 7.5 years, 1,813 patients met study criteria. Among patients who received a total of 1 to 2 or 3 to 5 units in the first 24 hours, there was no association between the amount and age of transfused blood and mortality. For patients who received a total of > or = 6 units, the presence of > or = 3 units of young blood was associated with a 3.8-fold increased odds of death (CI: 1.1-12.7), compared with a 7.8-fold (CI: 2.3-26.3) increased odds of death associated with the presence of > or = 3 units of old blood (p = 0.0024).

CONCLUSION

Although larger volumes of blood, irrespective of age, are associated with increased odds of mortality, the transfusion of blood stored beyond 2 weeks appears to potentiate this association despite a practice of universal leukoreduction. For patients who receive relatively smaller transfusion volumes, blood age appears to have no effect on mortality.

Anemia of Inflammation in Critically Ill Patients

Anemia is seen frequently in critically ill patients and has several etiologies. This article reviews the causes with an emphasis on the effects of inflammation, examines the risks and benefits of current therapies, and discusses novel treatment options.

Tracheostomy protocol: experience with development and potential utility

OBJECTIVES

To examine the feasibility and potential utility of a tracheostomy protocol based on a standardized approach to ventilator weaning.

DESIGN

Prospective, observational data collection.

SETTING

Academic medical center.

PATIENTS

Surgical intensive care unit patients requiring mechanical ventilatory support.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Tracheostomy practice in 200 patients was analyzed in relation to spontaneous breathing trial (SBT) weaning. Decision for, and performance of, tracheostomy occurred (median [interquartile range]) 5.0 (3.75-8.0) and 7.0 (5.0-10.0) days following initiation of mechanical ventilation, respectively. Duration of mechanical ventilation was greater in tracheostomy compared with nontracheostomy patients (15.0 [11.0-19.0] vs. 6.0 [4.0-8.0], p < .001). For patients requiring ventilatory support for > or = 20 days, 100% of patients were maintained via tracheostomy. A protocol based on weaning performance, which included technical considerations, was developed. Individuals who failed preliminary weaning assessment or SBT for 3 successive days following 5 days (nonreintubated patients) or 3 days (reintubated patients) of ventilatory support met tracheostomy criteria. The protocol was implemented on a pilot basis in 125 individuals. Of the 55 (44.0%) patients undergoing tracheostomy, 25 (45.5%) did so consistent with criteria. Eighteen patients (32.7%) underwent tracheostomy before the time interval of data collection targeting weaning protocol performance, and 12 patients (21.8%) passed SBT on one or more occasions, were not extubated, and proceeded to tracheostomy.

CONCLUSIONS

A standardized approach in which the decision for tracheostomy is based on objective measures of weaning performance may be a means of using this procedure more consistently and effectively.

Effects of leukoreduced blood on acute lung injury after trauma: a randomized controlled trial

OBJECTIVE

The requirement for a blood transfusion after trauma is associated with an increased risk of acute lung injury. Residual leukocytes contaminating red cells are potential mediators of this syndrome. The goal of this trial was to test our hypothesis that prestorage leukoreduction of blood would reduce rates of posttraumatic lung injury.

DESIGN

Double blind, randomized, controlled clinical trial.

SETTING

University-affiliated level I trauma center in King County, Seattle, WA.

PATIENTS

Two hundred sixty-eight injured patients requiring red blood cell transfusion within 24 hrs of injury.

INTERVENTIONS

Prestorage leukoreduced vs. standard allogeneic blood transfusions.

MEASUREMENTS AND MAIN RESULTS

We compared the incidence of acute lung injury and acute respiratory distress syndrome at early (< or = 72 hrs) and late (> 72 hrs) time points after injury. In a subset, we compared plasma levels of surfactant protein-D and von Willebrand factor antigen between intervention arms. Rates of acute lung injury (relative risk [RR] 1.06, 95% confidence interval [CI] .69-1.640) and acute respiratory distress syndrome (RR .96, 95% CI 0.48-1.91) were not statistically different between intervention arms early after injury. Similarly, no statistically significant effect of leukoreduced transfusion on rates of acute lung injury (RR .88, 95% CI .54-1.44) or acute respiratory distress syndrome (RR .95, 95% CI .58-1.57) was observed to occur late after injury. There was no significant difference in the number of ventilator-free days or in other ventilator parameters between intervention arms. No statistically significant effect of leukoreduced blood on plasma levels of surfactant protein-D or von Willebrand factor antigen was identified.

CONCLUSIONS

Prestorage leukoreduction had no effect on the incidence or timing of lung injury or on plasma measures of systemic alveolar and endothelial inflammation in a population of trauma patients requiring transfusion. The relationship between transfusion and lung injury is not obviously explained by mechanistic pathways involving the presence of transfused leukocytes.

A predictive model for massive transfusion in combat casualty patients

BACKGROUND

Massive transfusion (MT) is associated with increased morbidity and mortality in severely injured patients. Early and aggressive use of blood products in these patients may correct coagulopathy, control bleeding, and improve outcomes. However, rapid identification of patients at risk for MT has been difficult. We postulated that evaluation of clinical variables routinely assessed upon admission would allow identification of these patients for earlier, more effective intervention.

METHODS

A retrospective cohort study was conducted at a single combat support hospital to identify risk factors for MT in patients with traumatic injuries. Demographic, diagnostic, and laboratory variables obtained upon admission were evaluated. Univariate and multivariate analyses were performed. An algorithm was formulated, validated with an independent dataset and a simple scoring system was devised.

RESULTS

Three thousand four hundred forty-two patient records were reviewed. At least one unit of blood was transfused to 680 patients at the combat support hospital. Exclusion criteria included age less than 18 years, transfer from another medical facility, designation as a security internee, or incomplete data fields. The final number of patients was 302, of whom 26.5% (80 of 302) received a MT. Patients with MT had higher mortality (29 vs. 7% [p < 0.001]), and an increased Injury Severity Score (25 +/- 11.1 vs. 18 +/- 16.2 [p < 0.001]). Four independent risk factors for MT were identified: heart rate >105 bpm, systolic blood pressure <110 mm Hg, pH <7.25, and hematocrit <32.0%. An algorithm was created to analyze the risk of MT (area under the curve [AUC] = 0.839). In an independent data set of 396 patients the ability to accurately identify those requiring MT was 66% (AUC = 0.747).

CONCLUSIONS

Independent predictors for MT were identified in a cohort of severely injured patients requiring transfusions. Patients requiring a MT can be identified with variables commonly obtained upon hospital admission.

Blood component therapy in obstetrics

Hemorrhage is the leading cause of intensive care unit admission and one of the leading causes of death in the obstetric population. This emphasizes the importance of a working knowledge of the indications for and complications associated with blood product replacement in obstetric practice. This article provides current information regarding preparation for and administration of blood products, discusses alternatives to banked blood in the obstetric population, and introduces pharmacological strategies for treatment of hemorrhage.

Recombinant activated factor VII in spinal surgery: a multicenter, randomized, double-blind, placebo-controlled, dose-escalation trial

STUDY DESIGN

Randomized, placebo-controlled, double-blind, multicenter, Phase IIa study.

OBJECTIVE

To assess the safety and efficacy of recombinant-activated Factor VII (rFVIIa) in major spinal surgery.

SUMMARY OF BACKGROUND

Spinal fusion surgery can cause substantial blood loss and blood product transfusions. Recombinant FVIIa is approved for treatment of bleeding in patients with coagulation abnormalities and has been shown to reduce blood loss and transfusion requirements in surgery in patients with no underlying coagulopathy.

METHODS

Forty-nine patients undergoing fusion of 3 or more vertebral segments were randomized and treated on losing 10% of their estimated blood volume (with total expected surgical blood loss > or = 20%) and received 3 doses (2-hour intervals) of placebo (n = 13) or 30, 60, or 120 microg/kg rFVIIa (n = 12 per group). The primary endpoint was safety. A priori-defined efficacy endpoints included blood loss and transfusion requirements between placebo and each rFVIIa dose group, adjusted for surgery duration, number of segments fused, and estimated blood volume.

RESULTS

Serious adverse events did not occur at any greater frequency in any of the treatment groups. One patient (3 x 30 microg/kg rFVIIa) with advanced cerebrovascular disease (undiagnosed, trial exclusion criterion) died 6 days after surgery due to an ischemic stroke. Mean blood loss was as follows: 2270 mL for placebo; 1909, 1262, and 1868 mL for 3 x 30, 3 x 60, and 3 x 120 microg/kg rFVIIa, respectively (differences not statistically significant). Mean adjusted surgical blood loss was as follows: 2536 mL for placebo; 1120, 400, and 823 mL for 3 x 30, 3 x 60, and 3 x 120 microg/kg rFVIIa, respectively (P < or = 0.001). Mean surgical transfusion volume was reduced by 27% to 50% with rFVIIa treatment (not significant). The mean adjusted surgical transfusion volume was reduced by 81% to 95% with rFVIIa treatment (P < or = 0.002).

CONCLUSION

No safety concerns were indicated for the use of rFVIIa in patients at all doses tested; rFVIIa reduced adjusted blood loss and adjusted transfusions during spinal surgery.

A pediatric case of transfusion-related acute lung injury following bone marrow infusion

TRALI is a rare but serious complication associated with transfusion, and known to occur following infusion of all types of plasma-containing blood products. However, only one adult case of TRALI after allogenic marrow graft has been reported. In this study, we present a pediatric case possibly associated with allogenic marrow infusion. A 10-yr-old girl was referred to our hospital for the treatment of acute myeloid leukemia. She underwent allogenic bone marrow transplantation from her HLA-2-loci-mismatched mother. During conditioning, she suffered from bacterial sepsis, but it had improved with antibiotics until day 0 of transplantation. Two h after starting the marrow infusion, she developed severe hypoxia. We discontinued the infusion and started steroids, which improved her respiratory condition. However, she developed respiratory failure again after resuming infusion of the graft. Despite intensive care with mechanical ventilation, the patient died of endotoxin shock five days after transplantation. Although we could not identify the antibody which might have been involved in the respiratory distress, the clear temporal relationship between marrow infusion and respiratory distress suggested that similar acute lung injury to TRALI might have occurred following allogenic marrow infusion in the present case.

Duodenal angiosarcoma: an unusual cause of severe gastrointestinal bleeding

Angiosarcoma is a rare soft-tissue neoplasm that occurs most often in the skin and the subcutaneous tissues but very rarely in the gastrointestinal tract. We report a case of primary intestinal angiosarcoma with severe gastrointestinal bleeding. This patient was referred to our institute for shock with tarry-bloody stool and severe anemia. Panendoscopy revealed multiple duodenal polypoid tumors, and initial biopsy specimen showed poorly differentiated adenocarcinoma. The tumors were treated with pancreaticoduodenectomy, but the patient died 2 weeks after the operation as a result of acute respiratory distress syndrome. The pathology was consistent with angiosarcoma of the duodenum. In our experience, this tumor may cause severe bleeding, and surgery should be performed as soon as possible to prevent complications of hypovolemic shock.

Increased permeability-oedema and atelectasis in pulmonary dysfunction after trauma and surgery: a prospective cohort study

BACKGROUND

Trauma and surgery may be complicated by pulmonary dysfunction, acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), but the mechanisms are incompletely understood.

METHODS

We evaluated lung capillary protein permeability non-invasively with help of the 67Ga-transferrin pulmonary leak index (PLI) technique and extravascular lung water (EVLW) by the transpulmonary thermal-dye dilution technique in consecutive, mechanically ventilated patients in the intensive care unit within 24 h of direct, blunt thoracic trauma (n = 5, 2 with ARDS), and within 12 h of indirect trauma by transhiatal oesophagectomy (n = 8), abdominal surgery for cancer (n = 6) and bone surgery (n = 4). We studied transfusion history, haemodynamics, oxygenation and mechanics of the lungs. The lung injury score (LIS, 0-4) was calculated. Plain radiography was also done to judge densities and atelectasis.

RESULTS

The PLI and EVLW were elevated above normal in 61 and 30% of patients, respectively, and the PLI directly related to the number of red cell concentrates given (rs = 0.69, P < 0.001), without group differences. Oxygenation, lung mechanics, radiographic densities and thus the LIS (1.0 [0.25-3.5]) did not relate to PLI and EVLW. However, groups differed in oxygenation and airway pressures and impaired oxygenation related to the number of radiographic quadrants with densities (rs = 0.55, P = 0.007). Thoracic trauma patients had a worse oxygenation requiring higher airway pressures and thus higher LIS than the other patient groups, unrelated to PLI and EVLW but attributable to a higher cardiac output and thereby venous admixture. Finally, patients with radiographic signs of atelectasis had more impaired oxygenation and more densities than those without.

CONCLUSION

The oxygenation defect and radiographic densities in mechanically ventilated patients with pulmonary dysfunction and ALI/ARDS after trauma and surgery are likely caused by atelectasis rather than by increased permeability-oedema related to red cell transfusion.

Newly recognized causes of acute lung injury: transfusion of blood products, severe acute respiratory syndrome, and avian influenza

Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is a clinical syndrome that has an ever-growing list of potential causes. The transfusion of blood products is often a life-saving therapy, but it can be associated with the development of ALI/ARDS. Transfusion-related ALI is now the leading cause of transfusion-associated fatalities in the United States. Two infectious causes of ALI/ARDS, severe acute respiratory syndrome and H5N1 influenza, have recently emerged and have the potential for pandemic spread. This article discusses the clinical importance, pathogenesis, diagnosis, management, and prevention of these newly recognized causes of respiratory failure.

Erythropoiesis in multiply injured patients

Posttraumatic anemia in multiply injured patients is caused by hemorrhage, reduced red blood cell survival, and impaired erythropoiesis. Trauma-induced hyperinflammation causes impaired bone-marrow function by means of blunted erythropoietin (EPO) response, reduced iron availability, suppression and egress of erythroid progenitor cells. To treat posttraumatic anemia in severely injured patients, symptomatic therapy by blood transfusion is not sufficient. Furthermore, EPO, iron, and the use of red cell substitutes should be considered. The posttraumatic systemic inflammatory response syndrome (SIRS) induces posttraumatic anemia. Thus, a worsening of SIRS by a "second-hit" through blood transfusion ought to be avoided.