Recommendations for the management of trauma or surgery-related massive blood loss.

UNLABELLED: Exsanguination is an underestimated cause of treatment failures in patients with severe trauma or undergoing surgery. In some patients the primary dysfunction of blood clot formation is a direct cause of a massive blood loss. Patients without previous coagulation disorders are at risk of coagulopathy following intraoperative or post-traumatic bleeding, where the local haemostasis does not warrant bleeding cessation. THE AIM OF THE STUDY: was to assess the therapeutic value of various components of a complex interdisciplinary approach, based on the opinion of the experts treating patients with massive bleeding. MATERIAL AND METHODS: The study was conducted by anonymous questionnaire, using the analogue representation of the argument strength. The results were analyzed based on the techniques of descriptive statistics. The argument was considered a key parameter, when the median value of strength was located in the highest quartile. RESULTS: It was found that the arguments of the highest strength for the risk of developing the posthaemorrhagic coagulation disorders are: loss of more than one third of blood volume, fluid therapy in an amount greater than 35 ml/kg, administration of more than 5 units of packed red blood cells, insufficient supply of fresh frozen plasma and platelets in proportion to packed red blood cells, severe acidosis and hypothermia. The most important tests for post-haemorrhage coagulopathy are: anatomically non-localized bleed, abnormal values of the standard coagulation parameters and fibrinogen level below 1 g/L. In the treatment of post-haemorrhagic coagulopathy the team of experts pointed out the benefits of antifibrinolytic drugs, concentrates of prothrombin complex and recombinant activated coagulation factor VII. CONCLUSIONS: Multidisciplinary therapeutic management of bleeding patients is associated with employment of appropriate treatment methods to achieve the best possible outcome. Factors influencing the development of coagulopathy, the methods of diagnosis and proposed techniques of treatment may facilitate therapeutic decisions in bleeding patients requiring massive transfusion of blood components.

Perioperative bridging therapy with low molecular weight heparin for patients with inherited thrombophilia and antiphospholipid syndrome on long-term acenokumarol therapy.

The aim of the study is to present our own perioperative bridging therapy with low molecular weight heparin (LMWH) for surgical patients with thrombophilia on long-term acenokumarol therapy [oral anticoagulant (OAC)]. In some European countries, the drug used in secondary antithrombotic prophylaxis is acenokumarol. Forty-two patients with inherited thrombophilia and 21 with antiphospholipid syndrome underwent surgery. All patients were on long-term OAC. This OAC was interrupted 2 days before elective surgery and since that day half of the individual therapeutic dose of LMWH was administered. On day of surgery, the LMWH therapeutic dose was divided into two parts. Starting with day 2 after surgery, the patient was again given half of the individual dose of LMWH every 24 h. On day 4, OAC was additionally included. Both drugs were administered until stabilization of international normalized ratio (INR) values within the therapeutic target for 2 consecutive days. LMWH was then interrupted, whereas OAC continued. No symptoms or episodes of venous thromboembolism were observed. No intraoperative or postoperative hemorrhagic complications were reported. The results suggest that our perioperative bridging therapy is safe and effective for prevention of thromboembolic and hemorrhagic complications.

[Small volume resuscitation for acute intraoperative haemorrhage: comparison of 7.5% saline and 6% hydroxyethyl starch]. / Porównanie wplywu przetoczen malych objetosci 7,5% roztworu NaCL lub 6% roztworu hydroksy-etylowanej skrobi na zaburzenia hemodynamiczne, morfologiczne i elektrolitowe u chorych ze sródoperacyjna, ostra utrata krwi krazacej.

BACKGROUND: The immediate effect of acute haemorrhage is a significant reduction in tissue blood flow, frequently resulting in haemorrhagic shock. The main aim of resuscitation after bleeding is the immediate restoration of intravascular volume. Intravenous administration of volume expanders should be commenced immediately, regardless of whether they are colloids or electrolytes. The purpose of the study was to analyze haemodynamic changes during intraoperative acute bleeding and to compare the effects of intravenous infusion with 7.5% saline solution to 6% starch solution on the volume resuscitation process. METHODS: Sixty adult patients, of both sexes, in whom massive loss of blood followed by rapid cardiovascular collapse occurred during elective surgery, were enrolled in the study. In addition to standard fluid transfusion, all patients received either 4 mL kg(-1) of 7.5% NaCl solution or an equal volume of 6% of hydroxyethyl starch. Heart rate (HR) and mean arterial pressure (MAP) were noted. Cardiac output (CO) and systemic vascular resistance (SVR) were measured using a descending aortic blood flow ultrasound monitor. RESULTS: Massive intraoperative haemorrhage resulted in a rapid decrease in CO and SV with a simultaneous increase in HR and SVR in all patients. Injection of hypertonic salt or 6% HAES over 5 min increased the CO and SV. HR and SVR returned quickly to pre-existing levels and remained so until the end of the procedures. CONCLUSION: Small volume resuscitation with 7.5% saline or starch can be regarded as an efficient and effective method for restoring intravascular volume.

The KPC type beta-lactamases: new enzymes that confer resistance to carbapenems in Gram-negative bacilli.

Antimicrobial resistance due to the continuous selective pressure from widespread use of antimicrobials in humans, animals and agriculture has been a growing problem for last decades. KPC beta-lactamases hydrolyzed beta-lactams of all classes. Especially, carbapenem antibiotics are hydrolyzed more efficiency than other beta-lactam antibiotics. The KPC enzymes are found most often in Enterobacteriaceae. Recently, these enzymes have been found in isolates of Pseudomonas aeruginosa and Acinetobacter spp. The observations of blaKPC genes isolated from different species in other countries indicate that these genes from common but unknown ancestor may have been mobilized in these areas or that blaKPC-carrying bacteria may have been passively by many vectors. The emergence of carbapenem resistance in Gram-negative bacteria is worrisome because the carbapenem resistance often may be associated with resistance to many beta-lactam and non-beta-lactam antibiotics. Treatment of infections caused by KPC-producing bacteria is extremely difficult because of their multidrug resistance, which results in high mortality rates. Therapeutic options to treat infections caused by multiresistant Gram-negative bacteria producing KPC-carbapenemases could be used polymyxin B or tigecycline.

The aac(6')Ib gene in Proteus mirabilis strains resistant to aminoglycosides.

The aim of this study was to evaluate the presence of aac(6')-Ib gene conferring resistance to aminoglycosides in Proteus mirabilis strains. Five isolates had aac(6')-Ib gene. In one case the gene was no-expressed. Three isolates were resistant to all aminoglycosides and minimum inhibitory concentrations were > or = 256 microg/ml. Additionally, all positive strains were resistant to tetracycline and ciprofloxacin.

[Transfusion-Related Acute Lung Injury a serious, underdiagnosed transfusion-related event]. / Potransfuzyjna ostra niewydolnosc oddechowa--grozne, zbyt rzadko rozpoznawane powiklanie poprzetoczeniowe.

UNLABELLED: Transfusion-Related Acute Lung Injury (TRALI) has been diagnosed very rare until recent years. However, the growing interest in TRALI allows to asses, that it is the second commonest cause of transfusion association death. In Poland only single cases of TRALI have been published. AIM: We analyzed 34 cases with dyspnea reported as a post-transfusion event and examined leukocyte antibodies, which are supposed to be an important pathogenic factor in TRALI. RESULTS: 34 patients were classified into: the group A--patients with a pulmonary oedema after exclusion of other reasons (TRALI, n= 11); the group B-- patients with pulmonary oedema, but with difficulties to exclude other reasons (possible TRALI, n=15); the group C--post transfusion dyspnea without pulmonary oedema (patients where not classified as the TRALI, n=8). In all the groups other clinical symptoms were also analyzed. The leukocyte antibodies were most often detected in the group A (91%), less often in the group B (53%) and C (37.5%). CONCLUSIONS: Transfusion-related dyspnea should be individually analyzed before the final diagnosis of TRALI. If in the donor of transfused blood the leukocyte antibodies are detected, the "trace back" procedure should be started to see whether in other patients a transfusion-related dyspnea was diagnosed. This procedure is important for potential exclusion of a given donor from blood donation.