Utility of rotational thromboelastometry in the management of massive haemorrhage at a regional Australian hospital.

BACKGROUND: Rotational thromboelastometry (ROTEM) allows targeted and individualised blood product replacement. OBJECTIVES: The study aimed to determine the impact of ROTEM-guided transfusion on the clinical course of patients with acute massive haemorrhage in a regional Australian hospital. METHODS/MATERIALS: A retrospective review of all patients with acute massive haemorrhage that compared the characteristics, blood product use, and clinical outcomes of patients with massive haemorrhage before and after the introduction of ROTEM-guided transfusion. RESULTS: In per-protocol analysis, the 31/97 (32%) with ROTEM-guided transfusion used less packed red blood cells (median [interquartile range]: 6 [6-8] vs. 8 [6-12] units, p = 0.03) than patients whose transfusion was not ROTEM-guided. They were also less likely to receive fresh frozen plasma (2/31 [6%] vs. 45/66 [68%], p < 0.0001) or platelets (2/31 [6%] vs. 31/66 [47%], p < 0.0001); they were, however, more likely to receive fibrinogen products (26/31 [84%] vs. 38/66 [58%], p = 0.01). Patients receiving ROTEM-guided transfusion had lower in-hospital mortality (6/31 [19%] vs. 20/66 [30%], odds ratio 0.55 [95% confidence interval]: 0.20-1.55, p = 0.26) although this did not achieve statistical significance in this small cohort. CONCLUSION: ROTEM-guided massive transfusion of patients with acute haemorrhage in this regional Australian hospital led to a reduction in packed red blood cell, fresh frozen plasma, and platelet utilisation and may also have reduced mortality.

Comparison of surf lifesaver pressure point control and a commercial arterial tourniquet for major lower limb haemorrhage: A randomised controlled crossover pilot trial.

OBJECTIVE: This pilot study compared non-medically trained surf lifesavers' (SLS) ability, after infographic training, to occlude the femoral artery using a pressure point (PP) versus an arterial tourniquet (AT). METHODS: Using a crossover design, eight SLS applied PP and AT to a participant's leg to occlude the femoral artery. Arterial flow, application time and perceived difficulty were recorded. RESULTS: PP achieved 89.7% and 50.8% blood flow reduction for PP and AT, respectively. Average application time was 50.63 and 113.5 s for PP and AT, respectively. Perceived difficulty using a Likert scale from 0 to 10 (0 being no difficulty and 10 being maximal difficulty) was 2.75 and 3.50 for PP and AT, respectively. CONCLUSION: Infographic-trained SLS showed superior blood flow occlusion using PP. This pilot study will inform a larger trial for untrained beachgoers.

Documento multidisciplinar de consenso sobre el manejo de la hemorragia masiva. Primera actualización 2023 (documento HEMOMAS-II) / Multidisciplinary consensus document on the management of massive haemorrhage. First update 2023 (document HEMOMAS-II)

El presente documento supone una puesta al día del documento multidisciplinar HEMOMAS, publicado en el año 2016 con el aval de las Sociedades Científicas Españolas de Anestesiología y Reanimación (SEDAR), Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) y de Trombosis y Hemostasia (SETH). El objetivo de este documento fue revisar y actualizar las recomendaciones existentes sobre el manejo de la hemorragia masiva (HM). Se siguió una metodología basada en elementos del método ADAPTE (búsqueda y adaptación de guías publicadas en el ámbito específico de la HM desde 2014, más búsqueda bibliográfica en PubMed y EMBASE desde enero-2014 hasta junio-2021). Tras la revisión de nueve guías y 207 artículos seleccionados, se actualizaron las 47 recomendaciones existentes en el artículo original, manteniendo, suprimiendo o modificando cada una de ellas y sus grados de recomendación y evidencia. Consensuadamente, los autores aprobaron la redacción final del artículo y las 41 recomendaciones resultantes.(AU)

This document is an update of the multidisciplinary document HEMOMAS, published in 2016 with the endorsement of the Spanish Scientific Societies of Anaesthesiology (SEDAR), Intensive Care (SEMICYUC) and Thrombosis and Haemostasis (SETH). The aim of this document was to review and update existing recommendations on the management of massive haemorrhage. The methodology of the update was based on several elements of the ADAPTE method by searching and adapting guidelines published in the specific field of massive bleeding since 2014, plus a literature search performed in PubMed and EMBASE from January 2014 to June 2021. Based on the review of 9 guidelines and 207 selected articles, the 47 recommendations in the original article were reviewed, maintaining, deleting, or modifying each of them and the accompanying grades of recommendation and evidence. Following a consensus process, the final wording of the article and the resulting 41 recommendations were approved by all authors.(AU)

Multidisciplinary consensus document on the management of massive haemorrhage. First update 2023 (document HEMOMAS-II).

This document is an update of the multidisciplinary document HEMOMAS, published in 2016 with the endorsement of the Spanish Scientific Societies of Anaesthesiology (SEDAR), Intensive Care (SEMICYUC) and Thrombosis and Haemostasis (SETH). The aim of this document was to review and update existing recommendations on the management of massive haemorrhage. The methodology of the update was based on several elements of the ADAPTE method by searching and adapting guidelines published in the specific field of massive bleeding since 2014, plus a literature search performed in PubMed and EMBASE from January 2014 to June 2021. Based on the review of 9 guidelines and 207 selected articles, the 47 recommendations in the original article were reviewed, maintaining, deleting, or modifying each of them and the accompanying grades of recommendation and evidence. Following a consensus process, the final wording of the article and the resulting 41 recommendations were approved by all authors.

Documento multidisciplinar de consenso sobre el manejo de la hemorragia masiva. Primera actualización 2023 (documento HEMOMAS-II) / Multidisciplinary consensus document on the management of massive haemorrhage. First update 2023 (document HEMOMAS-II)

El presente documento supone una puesta al día del documento multidisciplinar HEMOMAS, publicado en el año 2016 con el aval de las Sociedades Científicas Españolas de Anestesiología y Reanimación (SEDAR), Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) y de Trombosis y Hemostasia (SETH). El objetivo de este documento fue revisar y actualizar las recomendaciones existentes sobre el manejo de la hemorragia masiva (HM). Se siguió una metodología basada en elementos del método ADAPTE (búsqueda y adaptación de guías publicadas en el ámbito específico de la HM desde 2014, más búsqueda bibliográfica en PubMed y EMBASE desde enero-2014 hasta junio-2021). Tras la revisión de nueve guías y 207 artículos seleccionados, se actualizaron las 47 recomendaciones existentes en el artículo original, manteniendo, suprimiendo o modificando cada una de ellas y sus grados de recomendación y evidencia. Consensuadamente, los autores aprobaron la redacción final del artículo y las 41 recomendaciones resultantes (AU)

This document is an update of the multidisciplinary document HEMOMAS, published in 2016 with the endorsement of the Spanish Scientific Societies of Anaesthesiology (SEDAR), Intensive Care (SEMICYUC) and Thrombosis and Haemostasis (SETH). The aim of this document was to review and update existing recommendations on the management of massive haemorrhage. The methodology of the update was based on several elements of the ADAPTE method by searching and adapting guidelines published in the specific field of massive bleeding since 2014, plus a literature search performed in PubMed and EMBASE from January 2014 to June 2021. Based on the review of 9 guidelines and 207 selected articles, the 47 recommendations in the original article were reviewed, maintaining, deleting, or modifying each of them and the accompanying grades of recommendation and evidence. Following a consensus process, the final wording of the article and the resulting 41 recommendations were approved by all authors (AU)

Laparoscopic management of an ileal lipoma presenting with massive gastrointestinal haemorrhage.

Small bowel lipomas are benign submucosal neoplasm composed mainly of mature adipose tissue. Despite their rare occurrence, lipomas are the second most common benign tumour of the small intestine. These tumours are mostly small in size and remain clinically asymptomatic. However, larger lesions tend to be more symptomatic, presenting with complications such as intussusception, bleeding or obstruction. Definitive surgical or endoscopic intervention is indicated in such symptomatic lipomas. Herein, we describe a rare case of ileal lipoma presenting with ileo-ileal intussusception and a life-threatening haemorrhage that was managed by laparoscopic-assisted ileal resection.

Thromboelastometry-guided treatment algorithm in postpartum haemorrhage: a randomised, controlled pilot trial.

BACKGROUND: Postpartum haemorrhage causes significant mortality among parturients. Early transfusion of blood products based on clinical judgement and conventional coagulation testing has been adapted to the treatment of postpartum haemorrhage, but rotational thromboelastometry (ROTEM) may provide clinicians means for a goal-directed therapy to control coagulation. We conducted a parallel design, randomised, controlled trial comparing these two approaches. We hypothesised that a ROTEM-guided protocol would decrease the need for red blood cell transfusion. METHODS: We randomised 60 parturients with postpartum haemorrhage of more than 1500 ml to receive either ROTEM-guided or conventional treatment, with 54 patients included in the final analysis. The primary outcome was consumption of blood products, and secondarily we assessed for possible side-effects of managing blood loss such as thromboembolic complications, infections, and transfusion reactions. RESULTS: The median (25th-75th percentile) number of RBC units transfused was 2 (1-4) in the ROTEM group and 3 (2-4) in the control group (P=0.399). The median number of OctaplasLG® units given was 0 in both groups (0-0 and 0-2) (P=0.030). The median total estimated blood loss was 2500 ml (2100-3000) in the ROTEM group and 3000 ml (2200-3100) in the control group (P=0.033). No differences were observed in secondary outcomes. CONCLUSIONS: ROTEM-guided treatment of postpartum haemorrhage could have a plasma-sparing effect but possibly only a small reduction in total blood loss. CLINICAL TRIAL REGISTRATION: NCT02461251.

The zone II aorta is not a forbidden zone for occlusion in women with morbidly adherent placenta.

AIM: To evaluate the safety and efficacy of balloon occlusion at the Zone II aorta for the management of morbidly adherent placenta. METHODS: From September 2015 to October 2018, a total of 80 consecutive patients who were prenatally diagnosed with morbidly adherent placenta were assigned into two groups: the balloon occlusion group (n = 40) and the non-balloon occlusion group (n = 40).The intraoperative estimated blood loss, blood transfusion, urine output, serum creatinine, blood urea nitrogen and hysterectomy rate were recorded and compared between the two groups. RESULTS: The estimated blood loss in the balloon occlusion group was significantly lower than that in the non-balloon occlusion group (811.75 ± 299.93 ml vs 1529.75 ± 808.01 ml, P < 0.001). The median amount of packed RBCs transfused in the balloon occlusion group and non-balloon occlusion group was 0 U and 2 U, respectively (P = 0.001). The women in the former group had a lower blood transfusion rate than those in the latter group (30% vs 57.5%, P = 0.013). Hysterectomy occurred in none in the balloon occlusion group but in six patients in the non-balloon occlusion group (P = 0.011). CONCLUSION: The middle abdominal aorta (Zone II) is not a forbidden zone for occlusion as long as the single occlusion time is limited to 15 min. Balloon occlusion at the Zone II aorta can effectively reduce blood loss, transfusion requirements and hysterectomy rates in patients with morbidly adherent placenta.

Systematic review and meta-analysis of arterial embolization compared with traditional management on outcomes of traumatic massive facial haemorrhage.

BACKGROUND: Maxillofacial trauma accounts for ~10% of trauma presentations to most centres, with massive haemorrhage occurring in 1.2-4.5% of cases. Despite its infrequent presentation, there is significant associated morbidity and mortality. Transcatheter arterial embolization (TAE) is playing an increasingly prominent role in trauma presentations. The aim of this article was to compare outcomes of TAE with more traditional management methods for the treatment of massive facial haemorrhage following maxillofacial trauma. METHODS: A database and Google Scholar search was performed, with articles discussing massive facial haemorrhage secondary to maxillofacial trauma and its management included. RESULTS: Twenty-seven articles were found that met inclusion criteria, encompassing 384 patients. Statistical testing comparing mortality between TAE and non-TAE groups did not find a significant difference, with a mortality rate of 30.2% in the TAE group and 38.9% in the non-TAE group. Assessment of morbidity directly related to interventions was difficult, as many of the included participants had significant associated injuries which contributed an indeterminate degree to morbidity. There was a 10% rate of adverse events associated with TAE, most commonly puncture site haematomas and soft tissue swelling, with more significant adverse events including cerebrovascular accidents and blindness. CONCLUSION: Embolization was correlated with increased rates of haemorrhage control when compared with other interventions. Overall, despite no significant impact on mortality, embolization is recommended in the management of massive haemorrhage following maxillofacial trauma due to improved success rates at haemorrhage control and a low rate of significant adverse events.

Management of submacular massive haemorrhage in age-related macular degeneration: comparison between subretinal transplant of human amniotic membrane and subretinal injection of tissue plasminogen activator.

PURPOSE: Macular neovascularization (MNV) can complicate age-related macular degeneration (AMD) and lead to severe visual acuity reduction. Massive submacular haemorrhage (SMH) is a sight-threatening complication of MNV and a challenge in the management of complications related to MNV in AMD since the effects of anti-vascular endothelial growth factor treatment alone are insufficient. Here, we evaluate the different postoperative outcomes of patients affected by MNV complicated by SMH that underwent subretinal implant of human amniotic membrane (hAM) or subretinal injection of tissue plasminogen activator (tPA). METHODS: This is a retrospective, consecutive, comparative, non-randomized interventional study. We included 44 eyes of 44 patients affected by AMD complicated by MNV and SMH. Twenty-two eyes underwent a pars plana vitrectomy (PPV), SMH and neovascular membrane removal, with a subretinal implant of hAM and silicone oil, and 22 eyes underwent PPV, subretinal injection of tPA, and 20% sulphur hexafluoride. The primary study outcome was visual acuity improvement. Secondary outcomes were postoperative complications, and MNV recurrence and optical coherence tomography (OCT)-Angiography parameters correlated with best-corrected visual acuity (BCVA). RESULTS: Mean preoperative BCVA was 1.9 logarithm of the minimal angle of resolution (logMAR) in the amniotic membrane-group and 2 logMAR in the tPA-group. The mean final BCVA values were 1.25 and 1.4 logMAR, respectively, with a statistically significant difference. Optical coherence tomography (OCT)-Angiography scan was be used to evaluate the retinal vascularization in the treated eye. CONCLUSION: Both techniques report similar VA improvements and postoperative complications. However, transplantation of hAM seems to have a significant benefit in inhibiting MNV recurrence.

Massive blood loss protocol 'Code Red' at Papworth Hospital: A closed loop audit.

AIM: To investigate if the massive blood loss protocol 'Code Red' at a specialist cardiothoracic hospital was activated according to local and national guidelines by a closed loop audit. METHODS: Electronic and paper patient care systems were searched in 2015 and 2018 to access records for the 'Code Red' activations. Activation of the massive blood loss protocol was compared against the national standards set by The British Committee for Standards in Haematology. The percentage of cases meeting each of the ten standards in the specialist cardiac unit's Protocol for the Management of Massive Blood Loss in Adults (adapted from the national standards) were evaluated. RESULTS: 'Code Red' protocol was activated on 18 occasions in 2015 and nine occasions in 2018, representing just 0.83 and 0.26% of emergency surgeries, respectively. Between 2015 and 2018, there was a 6% increase of 'Code Red' cases being appropriately activated, a 26% increase in the prompt notification of the haematology department upon activation, alongside a 30% increase in the timely delivery of blood products, and a 25% decrease in the average amount of blood transferred prior to 'Code Red' activation. CONCLUSION: There has been an improvement in the standards of care and management of massive blood loss this specialist cardiac centre despite the target timeframe being reduced from 30 to 15min between 2015 and 2018. Preparation for and anticipation of massive blood loss has likely decreased the number of incidences requiring 'Code Red' activation, permitting delivery of safe patient care.

Massive spontaneous haemorrhage in a plexiform neurofibroma: A case report and discussion of the literature.

Neurofibromatosis Type 1 (NF1) is a neurocutaneous tumour syndrome characterised by mutations in the NF1 gene and resultant neurofibromin protein. The condition is associated with several stigmata of variable penetrance, including various tumours. Massive and fatal haemorrhage arising from plexiform neurofibromas has been described in NF1 patients, though it is a rare clinical entity. The aetiology of massive haemorrhage in NF1 patients appears to be related to vasculopathy, including aneurysms and pseudoaneurysms, often arising within plexiform neurofibromas. There is currently no evidence-based consensus for managing this rare clinical emergency, likely as a result of its low incidence. We describe a case of massive haemorrhage in an NF1 patient managed via embolisation and discuss the literature.

Association between birth weight and massive haemorrhage in pregnancy with a low-lying placenta: a 9-year single-centre retrospective cohort study in Japan.

A low-lying placenta is a well-known cause of a massive intrapartum haemorrhage. We aimed to evaluate whether neonatal birth weight deviation from the nationwide average could predict a massive haemorrhage during a delivery in the women with a low-lying placenta. This study included 40 women. The main outcomes were a massive haemorrhage and a neonatal birth weight deviation. We used a receiver operating characteristic curve analysis to determine the optimal birth weight deviation cut-off for predicting a massive haemorrhage. A multiple logistic regression model was used to identify the variables significantly associated with a massive haemorrhage. The best cut-off for predicting a massive haemorrhage was a birth weight deviation of +0.51 standard deviations (SDs) from the nationwide average. A birth weight deviation of ≥ +0.51 SDs was significantly associated with an increased massive haemorrhage risk. Impact statement What is already known on this subject? A low-lying placenta is a well-known cause of a massive intrapartum haemorrhage. Therefore, when managing pregnancies with a low-lying placenta, the possibility of severe perinatal bleeding should be considered, and it is desirable to determine reliable predictors of a haemorrhage. However, few studies have reported the predictive factors of a massive haemorrhage in patients with a low-lying placenta. What do the results of this study add? We demonstrated that a birth weight deviation from the nationwide average was significantly associated with a massive intrapartum haemorrhage in patients with a low-lying placenta. To our knowledge, this is the first study to clarify the association between a neonatal birth weight and a massive intrapartum haemorrhage incidence and to determine the optimal birth weight deviation cut-off for predicting a massive haemorrhage in patients with a low-lying placenta. What are the implications of these findings for clinical practice and/or further research? An accurate risk stratification using the foetal weight as a marker for a predicting massive intrapartum haemorrhage may help in the management of patients with a low-lying placenta. Studies with a larger sample size are required to confirm our findings.

Massive Haemorrhage In Patient After Repair Of Post Esophagectomy Diaphragmatic Hernia And A Loading Dose Of Clopidogrel.

Postoperative diaphragmatic hernia (PDH) is an increasingly reported complication of esophageal cancer surgery. It occurs more frequently with minimally invasive techniques and very little is known about its pathogenesis. Currently, no consensus exists concerning preventive measures and its management. A 36 years old male underwent minimally invasive esophagectomy and presented with chest pain and dyspnoea in the emergency department 8 months after the procedure. He was started on acute coronary syndrome treatment protocol but was later diagnosed on CT scan to have diaphragmatic hernia through a defect in the oesophageal hiatus. As he was already loaded with dual anti platelet therapy it led to qualitative defect of the platelet which resulted in bleeding post procedure and the patient needed resuscitation with blood products. Dual anti-platelet therapy is an integral component of early management strategy in acute coronary syndrome. Chest X-ray was not helpful, but abdominal or chest computed tomography was useful for accurate diagnosis.

Massive Blood Transfusion during Revision Total Hip Arthroplasty under Combined Spinal Epidural Anaesthesia.

Revision total hip arthroplasty (THA) is an orthopaedic surgery that is known to be associated with excessive bleeding. The rates of mortality and morbidity are high in patients with massive haemorrhage. The patient in this study was administered blood products with high fresh frozen plasma/red blood cell (RBC) suspension ratio and high platelet/RBC suspension ratio without waiting for haemostasis test results. This study suggests that this approach might prove beneficial in reducing the incidence of intra- and postoperative complications. this study presents our experience with a patient who underwent THA and required a transfusion that was three times her estimated total blood volume. The patient was successfully managed with close monitoring of haemorrhage and timely administration of blood and blood products before hypotension and loss of consciousness occurred.

Clinical analysis and countermeasure research of bleeding during percutaneous nephrolithotomy by endoscopy and holmium laser / 局解手术学杂志

Objective To provide guidance for clinical prevention and treatment of bleeding during percutaneous nephrolithotomy( PC-NL) . Methods The clinical data of 1 012 patients with intraoperative and postoperative bleeding during percutaneous nephrolithotomy in our urology department were collected,hemorrhoea occurred on 36 cases,the occurrence rate was 3. 56%. The incidence,correlation with cal-culi,diabetes mellitus,examination item,technical operation were analyzed and compared. Results The incidence was 5. 52% for patients with complicated calculi. The incidence of delayed massive haemorrhage has been increased postoperatively in the diabetes mellitus patients. This incidence was 1. 81% for patients with preoperative examination. Along with the extension of time in carrying out technology,PCNL asso-ciated bleeding incidence decreased year by year. Conclusion The occurrence of haemorrhage associated with PCNL could be decreased by correctly handling complicated calculi,preoperative examination,keeping blood glucose homeostasis and improving the manipulation ability of operator.

Simulation training improves clinical knowledge of major haemorrhage management in foundation year doctors.

OBJECTIVES: (i) To develop a major haemorrhage simulation training programme. (ii) To design an assessment tool to measure the effectiveness of this programme. (iii) To use simulation training to create more effective protocols. BACKGROUND: Major haemorrhage is a time-critical medical emergency that can be faced by every Foundation Year (FY) doctor. Standard methods of teaching provide limited opportunity for junior doctors to improve their knowledge and practical skills for major haemorrhage situations. Simulation is increasingly used in medical training but has not been used as a means both to facilitate learning and refine hospital major haemorrhage policy. METHODS: The effect of major haemorrhage simulation on attendees' learning was compared to a comparator group not exposed to simulation. Questionnaire pre-simulation and 3 months post-simulation training assessed knowledge of the Trust Major Haemorrhage Protocol (MHP). RESULTS: Sixteen FY1 doctors attended simulation training. The comparator group included 47 FY1 doctors. No significant difference was found between simulation and comparator groups on baseline questionnaire scores. The simulation group showed significant improvement (total score, mean standard deviation (SD) pre-test 27.15 (4.02), post-test 39.13 (3.91), p < 0.001). The comparator group showed no significant change (total score, pre-test 25.06 (5.70), post-test 23.54 (6.85), p = 0.33) (19 lost to follow up). The study resulted in the production of a new MHP. CONCLUSION: This study has demonstrated that simulation training improved doctors' knowledge in major haemorrhage management and that the experience of observing the simulation training allowed senior staff to undertake analysis and improvement of an existing MHP.

Massive blood loss during tonsillectomy in a child with congenital venous malformation.

Tonsillectomy and adenoidectomy have become frequently performed outpatient procedures and are generally considered to have a low morbidity profile. Postoperative haemorrhage remains a rare but important complication, while intraoperative uncontrollable bleeding is extremely uncommon. A child with congenital vascular malformation of the lip and oropharynx undergoing tonsillectomy experienced massive blood loss, subsequent resuscitation and significant perioperative morbidity including a prolonged intensive care unit stay. Preoperative/preanaesthetic nasopharyngoscopic exam and magnetic resonance imaging did not reveal vascular prominence of the tonsils. Preoperative consideration of angiography or magnetic resonance angiography may be prudent to avoid this potentially fatal complication.