Total knee arthroplasty in severe haemophilic patients under continuous infusion of clotting factors.

PURPOSE: Haemophilic arthropathy is painful, invalidating and destructive. Authors report a prospective study of total knee arthroplasties in patients with severe haemophilia under continuous infusion of clotting factors. The purpose is to evaluate the benefits of continuous infusion of clotting factors regarding long-term functional improvement and radio-clinical results. METHODS: From 1998 to 2009, 20 total knee arthroplasties were implanted in 14 patients with a mean age of 36.5 years (24-56). A continuous infusion of anti-haemophilic factors was used and supervised by the physician of the Regional Haemophilia Treatment Centre (CRTH). Evaluation was clinical using the HSS and Oxford scores and radiological. RESULTS: One patient was lost to follow-up. Median follow-up is 66.5 months (6-134). Oxford score at latest follow-up is 42 (37-46). On revision, HSS score is 91 (84-96). Median flexion gain is 32.5° (-20; 75°). There is a median flexion contracture of 5° (0-15°) and a median extension improvement of 22.5°. We report 2 secondary infectious complications, concerning the same operated knee of a single patient. No post-operative haematoma was reported in our study. CONCLUSION: Total knee arthroplasty in haemophilic arthropathy improves both the function and quality of life of this group of patients. Continuous infusion of clotting factors contributes significantly to these results, by allowing early and intensive rehabilitation, and offers security regarding haemorrhagic complications commonly described in the literature and that we have not encountered in our study. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

Predictive factors of hyperfibrinolytic activity during liver transplantation in cirrhotic patients.

Hyperfibrinolytic activity occurs frequently during liver transplantation in cirrhotic patients. In order to identify those patients at high risk for increased intraoperative blood loss before operation, we determined predictive indicators of hyperfibrinolysis. We studied 56 cirrhotic patients undergoing liver transplantation with the same anaesthetic procedure and transfusion regimen. The preoperative coagulation patterns of the 11 patients who experienced acute intraoperative hyperfibrinolytic activity were compared with those of the 45 patients who did not suffer this complication. Before surgery, patients with intraoperative hyperfibrinolysis had decreased prothrombin time (PT) and euglobulin lysis time (ELT), and increased thrombin time (TT) and fibrinogen degradation products (FDP), whereas alpha angle and maximum amplitude (MA) were reduced on thrombelastography. Stepwise multivariate analysis disclosed three components which were significantly linked with occurrence of hyperfibrinolysis: TT, FDP and MA. Their sensitivity, specificity, positive and negative predictive values demonstrated that patients with FDP > or = 48 mg litre-1 and MA < or = 35 mm before incision had 100% probability of developing hyperfibrinolytic activity during transplantation.

[Anesthesia for MRI examination]. / Anesthésie pour examen IRM.

Magnetic resonance imaging (MRI) requires the patients to stay for 30-45 min in a magnetic closed noisy space. Therefore most children and agitated adults require general anaesthesia or sedation in order to high quality images. Anaesthesia may be given by several routes (TIVA, inhalational or intrarectal administration) using common drugs. However, the magnetic field limits the selection of patients undergoing MRI and the spectrum of anaesthetic and monitoring equipment. The magnetic field may have deleterious effects on implanted ferromagnetic devices. It may attract objects towards the magnet centre at a dangerous speed. Moreover it may disturb the function of monitors and anaesthesia machines which should be tested for a specific magnetic field strength before introducing their use in a given MRI unit.

[Multiple trauma in the elderly]. / Polytraumatisme et personnes âgées.

Morbidity and mortality following multiple trauma are high in elderly patients. Head trauma has a particularly poor prognosis. However intensive care may improve the survival rate and the quality of life in survivors, allowing those to return home.

[Monitoring of hemostasis during liver transplantation: contribution of thromboelastography]. / Surveillance de l'hémostase au cours de la transplantation hépatique: apport du thromboélastogramme.

Monitoring of coagulation is mandatory during liver transplantation (LT). Standard coagulation tests may be routinely used. However, they give static information and may be inadequate in case of severe coagulation defect. Interest has been recently focused on thromboelastography (TEG) which could give more suitable and rapid information in these cases. Few studies have evaluated the clinical interest of TEG compared to conventional tests. This comparison was the aim of the present study, performed in 89 patients scheduled for LT. The anaesthetic management as well as procedure of transfusion were similar in all patients. Before unclamping, 5000 KIU.kg-1 of aprotinin were injected. Routine tests and TEG were performed at the beginning and end of both pre-anhepatic and anhepatic phases, and 5, 30, 60, and 120 min after the revascularisation of the new liver. A phase of hypocoagulability was observed after unclamping. Biological signs included an increase in activated thromboplastin time, a reduction of alpha angle and maximum amplitude on TEG with a lengthening of its r + k component. A strong correlation existed between maximum amplitude and platelets, maximum amplitude and fibrinogen, alpha and fibrinogen at each time of the surgical procedure. Euglobulin lysis time decreased significantly after clamping, whereas fibrin degradation products increased at the same time. However, typical fibrinolysis with a clot lysis index (CLI) below 55% was only observed in 15 patients. Twelve of them had a CLI value reaching 0%, associated with severe generalized oozing. Aprotinin (200,000 to 600,000 KIU) corrected these abnormalities. These results show that TEG may not be very helpful to determine whether platelets or fibrinogen are involved in the phase of hypocoagulability detected after unclamping.(ABSTRACT TRUNCATED AT 250 WORDS)