The role of recombinant factor VIIa in the treatment of life-threatening haemorrhage in blunt trauma.

BACKGROUND: Recombinant factor VIIa (rFVIIa) is a novel haemostatic agent originally developed to treat bleeding in haemophiliacs. Several case reports suggest effectiveness of rFVIIa in the treatment of patients without pre-existing bleeding disorders. The aim of this study is to evaluate treatment with recombinant (rFVIIa) in blunt trauma patients with uncontrolled bleeding. PATIENTS AND METHODS: This study was designed as a retrospective case review. Consecutive patients with life-threatening uncontrolled bleeding due to blunt trauma who were treated with rFVIIa were selected. Data were obtained from medical records. RESULTS: A total of eight blunt trauma patients were treated with rFVIIa for uncontrolled bleeding. After treatment the need for transfusion of red blood cells (RBC) decreased significantly from 31.3 +/- 15.8 to 6.1 +/- 6.8 units (P = 0.003), fresh frozen plasma (FFP) from 13.3 +/- 6.6 to 5 +/- 6.3 units (P = 0.02), and platelets from 3.6 +/- 1.8 to 1.5 +/- 2.3 units (P = 0.01). Three patients died of non-bleeding complications. The other five fully recovered. CONCLUSION: Treatment with rFVIIa reduced or stopped bleeding in all patients. No adverse events were registered. Prospective studies are mandatory to elucidate the role of rFVIIa in blunt trauma.

[A 'blind' transfusion policy in patients with acute severe blood loss]. / 'Blind' transfusiebeleid bij patiënten met acuut ernstig bloedverlies.

Three patients presented with acute, excessive bleeding: a 54-year-old man following trauma to the pelvis, a 34-year-old woman with postpartum blood loss and a 62-year-old man with a duodenal ulcer. Treatment consisted of surgery, the administration of blood products and haemostatic agents, in varying strategies. The men recovered but the woman died as a result of cardiac rhythm disorders. It is unclear to what extent blood products should be used in patients with acute, excessive blood loss. Also, haemostatic agents have already found a place in the treatment of these patients, but it is unclear whether they should be administered early, as prophylaxis, or later when all other treatments have failed. While official registration of the haemostatic agent recombinant activated factor VII for this indication is pending, it is important that treatment with rFVIIa be embedded in a structured protocol to prevent overuse of blood products and administration of this medication to patients who do not need it. Controlled clinical trials for validation should be carried out prior to the implementation of such a protocol.

Percutaneous tracheostomy with the Blue Rhino trade mark technique: presentation of 100 consecutive patients.

We assessed the peri-operative, early and late complications in 100 percutaneous tracheostomies performed with the Blue Rhino trade mark kit. The success rate was 98%. Peri-operative complications occurred in 30 patients. Six major complications occurred; these included bleeding which required surgical exploration (n = 3), and pneumothoraces (n = 2) and one false passage. Cannula insertion was made easier by blunt dissection of the cervical tissues anterior to the trachea. The median duration of the procedure was 8.5 min, which is significantly longer than other authors' results. Only one major complication occurred while the patient was cannulated (serious bleeding requiring exploration). Finally, in a single patient a tracheal stenosis occurred as a major late complication which eventually was treated by a successful tracheal resection. Percutaneous tracheostomy with the Blue Rhino trade mark kit is safe with a low incidence of major complications.

Bacteria in blood smears: overwhelming sepsis or trivial contamination.

It is unusual to find microorganisms in peripheral blood smears, and their presence is frequently associated with overwhelming sepsis and consequently a poor prognosis. In this report, we demonstrate 4 cases with bacteria in blood smears. Two of them had a fatal outcome, but the other 2 were caused by a contamination either via the central venous catheter or in vitro, both without dramatic outcome. The finding of bacteria in blood smears has to be interpreted carefully, and thorough examination of peripheral blood smears may be of great importance in the early diagnosis of bacteremia; however, in vitro contamination must be excluded.

Malignant adenomyoepithelioma of the breast with metastasis in the thyroid gland 12 years after excision of the primary tumor. Case report and review of the literature.

We describe a patient who was admitted to our hospital with an enlarged left lobe of the thyroid gland. Since fine-needle aspiration showed atypical follicular cells, a surgical exploration followed. Owing to extensive tumor infiltration into the surrounding tissues curative surgery was not possible, and only an incisional biopsy was taken. Histological examination of this biopsy revealed a mixed tumor composed of epithelial and myoepithelial cells. A primary thyroid tumor, metastasis of a salivary gland, and a skin appendage tumor could be excluded based on clinical examination, conventional histology, and immunohistochemistry. A tumor of the left breast treated 12 years earlier had originally been classified as an intraductal/intracystic carcinoma with focal invasion, but was re-examined. Using immunohistochemistry, the breast tumor was reclassified as a malignant adenomyoepithelioma. The current tumor was apparently a metastasis from this primary breast tumor. An updated review of the literature is given, including current knowledge on histological and immunohistochemical features of adenomyoepithelioma of the breast, with special attention to the reported pathological characteristics of recurrent and malignant tumors. Based on the reported pathological characteristics of recurrent and metastatic tumors we offer a diagnostic tool for identifying potentially malignant and recurrent tumors.

[Successful electroconvulsive therapy in a pregnant woman with neuroleptic malignant syndrome]. / Succesvolle elektroconvulsietherapie bij een zwangere vrouw met het maligne neuroleptica-syndroom.

Neuroleptic malignant syndrome was diagnosed in a 27-year-old pregnant female with a psychiatric disorder, after treatment with haloperidol. The syndrome did not respond to treatment with dantrolene. Serious vegetative instability weighed against the use of electroconvulsive treatment. After 29 3/7 weeks of amenorrhoea electroconvulsive treatment was started, and the clinical picture gradually improved. Mother and child were discharged in good clinical condition.