Lactate and fibrinogen as good predictors of massive transfusion in postpartum hemorrhage.

AIM: This study aims to identify the clinical factors that can predict the requirement of massive transfusion among patients with postpartum hemorrhage (PPH). METHODS: Consecutive anonymized patients with PPH who were treated at the emergency department of our perinatal medical center were examined. Patients who had received transfusions before admission, those who had cardiac arrest on arrival, and those without history of blood gas analysis were excluded. Our primary outcome was the requirement of massive transfusion defined as packed red blood cells of ≥10 units/24 h. Univariable logistic analysis was carried out to identify the odds ratio and 95% confidence interval (CI) of the explanatory variables for the outcome. RESULTS: A total of 31 patients (massive transfusion, n = 19) were included in the main analysis. The crude odds ratio for fibrinogen per mg/dL and lactate per mmol/L were calculated as 0.98 (95% CI, 0.97-0.99) and 1.62 (95% CI, 1.08-3.02), respectively. The area under the curves for fibrinogen and lactate were 0.814 and 0.734, respectively, and optimal cut-off values for fibrinogen and lactate were 211 mg/dL and 4 mmol/L, respectively. CONCLUSION: These findings suggest that lactate and fibrinogen can be predictors for the requirement of massive transfusion in patients with PPH.

[Acute Ventilatory Failure during Prone Thoracoscopic Esophagectomy with Carbon Dioxide Insufflation in a Patient Managed by a Single Lumen Tracheal Tube].

A 67-year-old woman underwent prone thoracoscopic esophagectomy with carbon dioxide (CO2) insufflation. After insertion of an epidural catheter, general anesthesia was induced with propofol, sevoflurane, remifentanil and rocuronium. The trachea was intubated with a single lumen endotracheal tube (SLET). CO2 insufflation at 5 mmHg with the SLET deflated the right lung and provided excellent visualization without respiratory instability. The left side pleura was injured during the inferior mediastinal lymphadenectomy and the patient went into sudden profound hypoventilation with an increase in end-tidal CO2 from 43 to 64 mmHg. We observed the trachea with bronchofiberscope and the SLET was correctly located and not obstructed. We were convinced that bilateral pneumothorax occurred because the left side pleura was injured and auscultation revealed decreased breath sounds over the left hemithorax. We asked the surgeon to discontinue the insufflated CO2 and both lungs were fully expanded. The operation was then carried out successfully without further untoward event. The patient was successfully extubated at the intensive care unit on postoperative day 1. The CO2 insufflation during thoracoscopic esophagectomy can cause bilateral pneumothorax and we recommend to inflate the bilateral lungs regularly for the continuation of the surgery.

[Strategy for Determining the Appropriate Dose of Sugammadex with Monitoring Train-of-four (TOF) Responses at the End of Surgery].

BACKGROUND: Intraoperative monitoring of train-of-four (TOF) response is recommended to avoid inadequate dose of muscle relaxant and its antagonist. We have standardized monitoring of TOF response at the end of surgery in all the patients undergoing general anesthesia with rocuronium since October 2013. METHODS: TOF group comprised of 113 consecutive patients just after the standardization and we investigated the relationship between the dose of sugammadex and TOF count and also compared anesthetic factors in TOF group with those in control group which included 104 consecutive patients just before the standardization without TOF monitoring. RESULTS: Rate of the patients with TOF count 4 in TOF group approximately reached 70% and mean TOF ratio resulted in 0.56 ± 0.28. Mean dose of sugammadex in patients with TOF count 2-4 was 2.5 ± 0.9 mg x kg(-1), while the dose in patients with TOF count 0-1 was 3.6 ± 0.9 mg x kg(-1) and 6 patients among 11 patients with TOF count 0 was given less than 4 mg x kg(-1) of sugammadex. The percentage of the patients given 200 mg of sugammadex significantly decreased from 78% in control group to 48% in TOF group. CONCLUSIONS: We conclude that standardization of TOF response at the end of surgery reduces dose of sugammadex in patients with slight residual neuromuscular block though the dose in patients under deep muscle relaxation seems to be insufficient.