RESUMO
While specific practices and transported blood products vary around the world, most of the respondents in this International Forum transported at least one blood product for the transfusion to bleeding patients en route to the hospital. The most commonly carried product was RBCs, while the use of whole blood will likely increase given the recent reports of its successful use in the civilian setting, and because of the change in the AABB's Standards regulating its use. It will be interesting to see if plasma use in the prehospital setting becomes more widely used given today's enhanced appreciated of the coagulopathy of trauma and plasma's beneficial effect in reversing it, and if blood products are transported to the scene of injury by more vehicles, that is, not just predominantly in helicopters. It was not surprising that TXA is being widely administered as close to the time of injury as possible given its potential benefit in these patients. This International Forum highlights the importance of focusing attention on prehospital transfusion management with a need to further highquality research in this area to guide optimal resuscitation strategies.
Assuntos
Transfusão de Sangue/métodos , Congressos como Assunto , Serviços Médicos de Emergência/métodos , Hemorragia/terapia , Substitutos Sanguíneos/uso terapêutico , HumanosRESUMO
Background: Warm fresh whole blood (WFWB) is an ideal resuscitation fluid for exsanguinating patients but there are myriad logistic and infectious issues associated with its use. Cold whole blood (CWB) may be an acceptable alternative to the reconstituted whole blood (RWB), the current standard of care. A leukoreduction filter has been developed which maintains platelet count while eliminating white blood cells but its effect on platelet function is unknown. We hypothesize that CWB will retain an acceptable functional coagulation profile after filtration and over time. Study Design and Methods: WFWB and CWB samples were obtained from eight donors and four units of RWB were created. The quantitative and qualitative in vitro coagulation profiles of WFWB, RWB, and CWB over time were compared. Results: Filtration was successful at removing white blood cells (5.5 ± 1.2 vs. 0.3 ± 0.3 × 106/L) while retaining an adequate platelet count (172.0 ± 47.0 to 166.0 ± 42.3 × 109/L) and hemoglobin concentration (13.7 ± 0.5 vs. 13.0 ± 0.7 g/dL). Rotational Thromboelastography (ROTEM) results revealed a similar clotting time (CT) before and after filtration (64.9 ± 5.1 vs. 64.1 ± 6.8 s) but a decreased maximum clot firmness (MCF) (58.6 ± 4.2 vs. 54.9 ± 4.6 mm). Platelet aggregation decreased substantially (28.8 ± 6.7 vs. 9.3 ± 2.1 ohm) immediately after filtration. CWB function continued to diminish over time. Conclusion: CWB holds great promise as a surrogate for WFWB, but use of a platelet-sparing LR filter diminishes platelet function almost immediately after filtration.
Assuntos
Traumatismo Múltiplo/diagnóstico , Traumatismo Múltiplo/terapia , Ressuscitação/métodos , Traumatologia/métodos , Acidose/etiologia , Acidose/prevenção & controle , Transtornos da Coagulação Sanguínea/etiologia , Transtornos da Coagulação Sanguínea/prevenção & controle , Hemorragia/etiologia , Hemorragia/prevenção & controle , Humanos , Hipotermia/etiologia , Hipotermia/prevenção & controle , Laparotomia/métodos , Traumatismo Múltiplo/complicações , Reoperação/métodosRESUMO
Because 36% of intentional injury victims are drug dependent, the association between drug abuse and violence, especially in urban settings, is high. Withdrawal syndromes in ICU patients confuse their clinical management, may be extremely difficult to diagnose, are often lethal, need to be suspected, and should be prophylaxed against; therefore, all ICU patients should be considered to be at high risk for drug or alcohol dependence, should be tested for evidence of such drugs, and should be interviewed (together with their family members) for the presence of drug dependence traits. Appropriate patients should be referred for formal evaluation and treatment. Withdrawal syndromes must be promptly recognized, differentiated from traumatic or metabolic deterioration, and immediately treated. As patients are unique, so is their drug dependence. Individualized withdrawal therapy, not a "one method fits all" approach, works best. The mainstay of most withdrawal therapy is supportive care and benzodiazepine therapy. Also, considering the high rate of multiple intoxicants present in trauma patients, withdrawal can occur from multiple agents in a single patient, further compounding these difficulties. Withdrawal from unusual substances, such as GHB, or from therapeutic interventions (e.g., prolonged opioid or benzodiazepine administration) also must be considered.
Assuntos
Cuidados Críticos , Síndrome de Abstinência a Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Álcool/complicações , Transtornos Relacionados ao Uso de Álcool/diagnóstico , Transtornos Relacionados ao Uso de Álcool/terapia , Causas de Morte , Transtornos Relacionados ao Uso de Cocaína/complicações , Transtornos Relacionados ao Uso de Cocaína/diagnóstico , Transtornos Relacionados ao Uso de Cocaína/terapia , Diagnóstico Diferencial , Humanos , Transtornos Relacionados ao Uso de Opioides/complicações , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/terapia , Fatores de Risco , Síndrome de Abstinência a Substâncias/complicações , Síndrome de Abstinência a Substâncias/terapia , Transtornos Relacionados ao Uso de Substâncias/complicações , Transtornos Relacionados ao Uso de Substâncias/terapia , Saúde da População Urbana , Violência , Ferimentos e Lesões/complicações , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapiaRESUMO
Organ transplantation continues to be hindered by a limited supply of organs. A significant percentage of potential organ donors are lost to either medical failure or inability to obtain consent for donation. In a surgical intensive care unit (ICU) we have refocused our efforts toward aggressive resuscitation, directed by control of coagulopathy, invasive monitoring, and dedicated ICU management while implementing a rapid brain death determination protocol. Over a 6-year period the length of stay until the legal determination of brain death is made has been significantly shortened (12.0 vs. 3.4 hours; p < 0.05), as have associated charges despite this more aggressive approach. As a result, we have eliminated medical failures prior to donation (13% vs. 0%) and increased consent rates (44% vs. 71%; p < 0.05). These efforts have significantly improved the number of organs harvested per eligible donor (1.8 vs. 3.4; p < 0.05). In addition, the number of organs per actual donor has increased and is now markedly greater than the U.S. national average (4.7 vs. 3.7). We believe the approach presented, if widely applied, could potentially improve the current organ supply shortage.
Assuntos
Doadores de Tecidos , Obtenção de Tecidos e Órgãos/métodos , Transtornos da Coagulação Sanguínea/prevenção & controle , Morte Encefálica/diagnóstico , Cuidados Críticos , Humanos , Consentimento Livre e Esclarecido , Tempo de Internação , Monitorização Fisiológica , Transplante de Órgãos/estatística & dados numéricos , Pennsylvania/epidemiologia , Ressuscitação , Doadores de Tecidos/estatística & dados numéricos , Doadores de Tecidos/provisão & distribuição , Estados Unidos/epidemiologiaRESUMO
Blindness characterized by dilated unresponsive pupils and funduscopic evidence of varying degrees of vitritis, retinal vasculitis, retinitis, chorioretinitis, and optic neuritis developed in 21 alpacas and 1 llama within a 30-day period. The animals were part of a group of approximately 100 animals imported from Chile one year earlier. The animals had spent 6 months in quarantine and then, for the 6 months preceding the epizootic, were housed at an exotic animal import-export farm, where the disease developed. Four of the affected animals also had signs of neurologic dysfunction. A herpesvirus indistinguishable from equine herpesvirus I was isolated from 4 of the affected animals, and antibody titers diagnostic for equine herpesvirus I were demonstrated in the serum of all but one of the affected animals.
Assuntos
Artiodáctilos , Cegueira/veterinária , Camelídeos Americanos , Surtos de Doenças/veterinária , Encefalite/veterinária , Infecções por Herpesviridae/veterinária , Animais , Cegueira/etiologia , Cegueira/patologia , Encefalite/etiologia , Encefalite/patologia , Olho/patologia , Infecções por Herpesviridae/etiologia , Infecções por Herpesviridae/patologia , Herpesvirus Equídeo 1/isolamento & purificação , Oftalmoscopia/veterinária , Disco Óptico/patologia , Nervo Óptico/patologia , Retina/patologiaRESUMO
Flexible carbon fibre implants have been used in 40 cases of chronic ankle instability. The carbon fibre implant permits retention of inversion, does not interfere with peroneal function and is simple to insert. Thirty-seven cases were available for review 46 months after surgery. In 35 cases normal stability had been restored, and 22 patients continued to have an excellent result when reviewed. In 13 cases the implant was subsequently removed, and where no other stabilizing operation was carried out instability recurred. The problems necessitating implant removal have been recognized, and the technique modified to prevent their recurring.
Assuntos
Articulação do Tornozelo/cirurgia , Carbono , Instabilidade Articular/cirurgia , Próteses e Implantes , Adulto , Fibra de Carbono , Doença Crônica , Feminino , Seguimentos , Humanos , Ligamentos Articulares/cirurgia , MasculinoRESUMO
Carbon fibre may be used to repair rupture of the extensor mechanism of the knee when this involves either the patellar ligament or quadriceps tendon. The operative technique is described and the results in five patients are reviewed. This technique may be successful even after other forms of repair have failed.
Assuntos
Carbono , Patela/cirurgia , Suturas , Traumatismos dos Tendões/cirurgia , Adulto , Idoso , Fibra de Carbono , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ruptura , Fatores de TempoRESUMO
On the basis of eight years of experimental and clinical investigations, the author recommends carbon fiber on a trial basis to patients with chronic ligamentous instability and where function has been severely compromised because of the injury.
Assuntos
Carbono , Ligamentos Articulares , Próteses e Implantes , Tendões , Animais , HumanosRESUMO
Sixty-three knees with chronic ligamentous instability treated with flexible carbon fibre are reviewed. Assessment was by pre-operative and postoperative grading of function in work and sport, together with a subjective evaluation of the result based on stability. Fifteen knees had collateral repairs, seven had cruciate repairs and 41 had combined collateral and cruciate repairs. Overall, 71% of knees showed improvement in function and 67% had good or excellent results subjectively. Clinical examination did not correlate well with the patient's evaluation of the result. Nineteen unselected cases with intra-articular (cruciate) carbon fibre had arthroscopies. Infiltration of collagen tissues into the cruciate replacement was a slower process than at the extra-articular (collateral) site. There was no clinical or macroscopic evidence of synovitis but microscopically there was evidence of synovial irritation.
Assuntos
Carbono , Instabilidade Articular/cirurgia , Articulação do Joelho/cirurgia , Ligamentos Articulares/cirurgia , Próteses e Implantes , Artroscopia , Fibra de Carbono , Feminino , Humanos , Instabilidade Articular/fisiopatologia , Articulação do Joelho/fisiopatologia , Ligamentos Articulares/patologia , Masculino , Métodos , Cuidados Pós-Operatórios , Estresse Mecânico , Membrana Sinovial/patologia , Fatores de TempoRESUMO
Ruptures of the calcaneal tendon which present late may be repaired using carbon fibre to induce a neotendon. The operative technique is described and the results of five cases reviewed. The average muscle power obtained was 88% of normal, and the thickness of the neotendon was 148% of that of the normal side. It would appear that this tendon formation in man is comparable to that previously described in sheep.