Is dilutional coagulopathy induced by different colloids reversible by replacement of fibrinogen and factor XIII concentrates?

BACKGROUND: In this in vitro trial, we assessed the effect on blood coagulation of 60% dilution with different colloids and investigated reversibility by replacement of factor XIII (F XIII), fibrinogen, and the combination of fibrinogen and F XIII. METHODS: Using the blood of 12 volunteers, the following measurements were performed at baseline and after 60% dilution with (hydroxyethyl starch solutions) HES 130/0.42, gelatin, or balanced gelatin solution: blood gas analyses, coagulation factor concentrations (F I, F II, F VII, F VIII, F XIII), impedance aggregometry (Multiplate®), and rotational thromboelastometry (ROTEM). Then F XIII and fibrinogen as well as a combination of both were added, in concentrations corresponding to 6 g fibrinogen and 1250 IU F XIII in adults. ROTEM measurements and determination of factor concentrations were again performed. RESULTS: Colloid dilution led to a significant reduction of fibrinogen polymerization, especially with HES. Platelet function was impaired by all colloids, with gelatin having a significantly greater effect (area under the curve, collagen Test, P ≤ 0.008) than HES and balanced gelatin solution. The substitution of F XIII only did not improve clot formation. Substitution of fibrinogen improved the polymerization of fibrinogen in dilutions with gelatin and balanced gelatin solution (P = 0.002), whereas HES-induced coagulopathy could not be corrected. The combination of fibrinogen and F XIII showed a better effect than the addition of fibrinogen only for certain variables. CONCLUSION: Coagulation and platelet function are impaired by all 3 colloids. However, in vitro gelatin-induced coagulopathy was significantly more reversible than HES-induced coagulopathy.

Early post-anaesthesia recovery parameters - a prospective observational study.

STUDY OBJECTIVES: To evaluate the patients' baseline condition upon arrival in the PACU as a method of assessment of the quality of anaesthesia, and to establish a model for future comparisons. DESIGN: Prospective observational study. SETTING: Surgical PACU in an academic tertiary hospital. PATIENTS: All patients (n = 11,241) arriving in our hospital's recovery units after elective surgery. INTERVENTIONS: In this observational study, clinical data, vital signs and comfort parameters were collected from surgical patients who arrived in the PACU. For each parameter, its frequency distribution or percentage of occurrence was determined. MAIN RESULTS: The incidence of anaesthesia associated side effects such as hypoxemia, cold extremities, shivering and/or vomiting was 5%. The incidence of nausea, sore throat, headache and/or pruritus was 9%. Sore throat occurred in 4.8% of intubated patients, in 4% after laryngeal mask insertions and in 3.6% with no usage of any airway device. From all patients 48% had no pain at all (VAS = 0), 31% had low pain scores (VAS 1-3) and 16% had moderate (VAS 4-6) pain levels, while 5% indicated severe pain (VAS 7-10). 97.5% of patients were normothermic (35.0-37.3°C), 77% had normal heart rate (60-100 beats per minute) and 74% had normal systolic blood pressure (90-140 mmHg). After use of neuromuscular relaxants, moderate clinical signs of residual curarisation (2 of 3 clinical criteria positive) were observed in 1% and slight clinical signs of residual curarisation (1 of 3 clinical criteria positive) were observed in 22.4% of patients. These findings were collected in all patients, independently whether they had reversal of neuromuscular relaxation. CONCLUSIONS: Compared with the figures published in the literature, we report a lower incidence and severity of anaesthesia related side effects, measured as baseline data, upon patients' arrival in the post anaesthesia care unit. The baseline data may serve as a model to trigger specific interventions aimed at improving the quality of anaesthetic care, which could be assessed in future investigations.

Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland.

BACKGROUND: The aim of this study was to investigate the impact of the introduction of a Patient Blood Management (PBM) programme in elective orthopaedic surgery on immediate pre-operative anaemia, red blood cell (RBC) mass loss, and transfusion. MATERIALS AND METHODS: Orthopaedic operations (hip, n=3,062; knee, n=2,953; and spine, n=2,856) performed between 2008 and 2011 were analysed. Period 1 (2008), was before the introduction of the PBM programme and period 2 (2009 to 2011) the time after its introduction. Immediate pre-operative anaemia, RBC mass loss, and transfusion rates in the two periods were compared. RESULTS: In hip surgery, the percentage of patients with immediate pre-operative anaemia decreased from 17.6% to 12.9% (p<0.001) and RBC mass loss was unchanged, being 626±434 vs 635±450 mL (p=0.974). Transfusion rate was significantly reduced from 21.8% to 15.7% (p<0.001). The number of RBC units transfused remained unchanged (p=0.761). In knee surgery the prevalence of immediate pre-operative anaemia decreased from 15.5% to 7.8% (p<0.001) and RBC mass loss reduced from 573±355 to 476±365 mL (p<0.001). The transfusion rate dropped from 19.3% to 4.9% (p<0.001). RBC transfusions decreased from 0.53±1.27 to 0.16±0.90 units (p<0.001). In spine surgery the prevalence of immediate pre-operative anaemia remained unchanged (p=0.113), RBC mass loss dropped from 551±421 to 404±337 mL (p<0.001), the transfusion rate was reduced from 18.6 to 8.6% (p<0.001) and RBC transfusions decreased from 0.66±1.80 to 0.22±0.89 units (p=0.008). DISCUSSION: Detection and treatment of pre-operative anaemia, meticulous surgical technique, optimal surgical blood-saving techniques, and standardised transfusion triggers in the context of PBM programme resulted in a lower incidence of immediate pre-operative anaemia, reduction in RBC mass loss, and a lower transfusion rate.