Global availability of parenteral nutrition: Pre- and post-COVID-19 pandemic surveys.

OBJECTIVE: Parenteral nutrition represents a therapeutic option for patients with type 3 intestinal failure. If used exclusively, parenteral nutrition has to be complete to provide all essential nutrients. The aim was to assess the availability of parenteral nutrition in all parts of the world, to better comprehend the global situation, and to prepare an action plan to increase access to parenteral nutrition. METHODS: An international survey using an electronic questionnaire was conducted in August 2019 and repeated in May 2022. An electronic questionnaire was sent to 52 members or affiliates of the International Clinical Nutrition Section of the American Society for Parenteral and Enteral Nutrition. Questions addressed the availability of parenteral nutrition admixtures and their components, reimbursement, and prescribing pre- and post-COVID-19 pandemic. All participating countries were categorized by their economic status. RESULTS: Thirty-six country representatives responded, answering all questions. Parenteral nutrition was available in all countries (100%), but in four countries (11.1%) three-chamber bags were the only option, and in six countries a multibottle system was still used. Liver-sparing amino acids were available in 18 (50%), kidney-sparing in eight (22.2%), and electrolyte-free in 11 (30.5%) countries (30.5%). In most countries (n = 28; 79.4%), fat-soluble and water-soluble vitamins were available. Trace elements solutions were unavailable in four (11.1%) countries. Parenteral nutrition was reimbursed in most countries (n = 33; 91.6%). No significant problems due to the coronavirus pandemic were reported. CONCLUSIONS: Despite the apparent high availability of parenteral nutrition worldwide, there are some factors that may have a substantial effect on the quality of parenteral nutrition admixtures. These shortages create an environment of inequality.

Metabolic failure due to thiamine deficiency during critical illness.

PURPOSE OF REVIEW: Thiamine is a crucial component in cellular energy metabolism, serving as a cofactor for multiple enzymatic processes and also having a role in regulating neuronal and neuromuscular transmission. Also it exerts antioxidant proprieties. The objective of this review is to consolidate and assess the most recent research concerning the consequences of insufficient thiamine levels for critically ill patients and to examine thiamine-related interventions. RECENT FINDINGS: Recent studies have unveiled a noteworthy association between thiamine deficiency and unfavorable consequences, such as heightened morbidity and fatality rates. The aforementioned deficiency exhibits a significant presence in medical situations such as starvation and alcohol use disorder, but also in patients during critical illness. Thiamine deficiency can have significant metabolic implications resulting in compromised energy generation and organ dysfunction, warranting prompt recognition and management. SUMMARY: Thiamine deficiency may not be recognized in critical care. Timely identification and management are imperative to mitigate adverse outcomes and improve patient prognosis. Thiamine may offer benefits for specific patient groups at higher risk of deficiency. Future studies should focus to establish optimal dosing, timing, and monitoring strategies on understanding the pathophysiological changes associated with thiamine deficiency in ICU patients and clarify its role in improving clinical outcomes.

Biodetoxification Using Intravenous Lipid Emulsion, a Rescue Therapy in Life-Threatening Quetiapine and Venlafaxine Poisoning: A Case Report.

The administration of intravenous lipid emulsion (ILE) is a proven antidote used to reverse local anesthetic-related systemic toxicity. Although the capacity of ILE to generate blood tissue partitioning of lipophilic drugs has been previously demonstrated, a clear recommendation for its use as an antidote for other lipophilic drugs is still under debate. Venlafaxine (an antidepressant acting as a serotonin-norepinephrine reuptake inhibitor (SNRI)) and quetiapine (a second-generation atypical antipsychotic) are widely used in the treatment of psychotic disorders. Both are lipophilic drugs known to induce cardiotoxicity and central nervous depression. We report the case of a 33-year-old man with a medical history of schizoaffective disorder who was admitted to the emergency department (ED) after having been found unconscious due to a voluntary ingestion of 12 g of quetiapine and 4.5 g of venlafaxine. Initial assessment revealed a cardiorespiratory stable patient but unresponsive with a GCS of 4 (M2 E1 V1). In the ED, he was intubated, and gastric lavage was performed. Immediately after the admission to the intensive care unit (ICU), his condition quickly deteriorated, developing cardiovascular collapse refractory to crystalloids and vasopressor infusion. Junctional bradycardia occurred, followed by spontaneous conversion to sinus rhythm. Subsequently, frequent ventricular extrasystoles, as well as patterns of bigeminy, trigeminy, and even episodes of non-sustained ventricular tachycardia, occurred. Additionally, generalized tonic-clonic seizures were observed. Alongside supportive therapy, antiarrhythmic and anticonvulsant therapy, intravenous lipid emulsion bolus, and continuous infusion were administered. His condition progressively improved over the following hours, and 24 h later, he was tapered off the vasopressor. On day 2, the patient repeated the cardiovascular collapse and a second dose of ILE was administered. Over the next few days, the patient's clinical condition improved, and he was successfully weaned off ventilator and vasopressor support. ILE has the potential to become a form of rescue therapy in cases of severe lipophilic drug poisoning and should be considered a viable treatment for severe cardiovascular instability that is refractory to supportive therapy.

A Trend towards Diaphragmatic Muscle Waste after Invasive Mechanical Ventilation in Multiple Trauma Patients-What to Expect?

Considering the prioritization of life-threatening injuries in trauma care, secondary dysfunctions such as ventilator-induced diaphragmatic dysfunction (VIDD) are often overlooked. VIDD is an entity induced by muscle inactivity during invasive mechanical ventilation, associated with a profound loss of diaphragm muscle mass. In order to assess the incidence of VIDD in polytrauma patients, we performed an observational, retrospective, longitudinal study that included 24 polytraumatized patients. All included patients were mechanically ventilated for at least 48 h and underwent two chest CT scans during their ICU stay. Diaphragmatic thickness was measured by two independent radiologists on coronal and axial images at the level of celiac plexus. The thickness of the diaphragm was significantly decreased on both the left and right sides (left side: -0.82 mm axial p = 0.034; -0.79 mm coronal p = 0.05; right side: -0.94 mm axial p = 0.016; -0.91 coronal p = 0.013). In addition, we obtained a positive correlation between the number of days of mechanical ventilation and the difference between the two measurements of the diaphragm thickness on both sides (r =0.5; p = 0.02). There was no statistically significant correlation between the body mass indexes on admission, the use of vitamin C or N-acetyl cysteine, and the differences in diaphragmatic thickness.

Same Clinical Reality of Spontaneous Rupture of the Common Iliac Artery with Pseudoaneurysm Formation-Comparison of Two Therapeutical Solutions, Endovascular Stent-Graft and Open Surgical Correction, for Two Cases and Review of the Literature.

The incidence of isolated iliac artery aneurysms is approximately 2% and common iliac artery pseudoaneurysms are even rarer. A pseudoaneurysm is a localized hemorrhage as opposed to an actual aneurysm, which affects the entire vascular wall. They are typically asymptomatic and only detectable accidentally while looking for other causes. If large and symptomatic, they typically exhibit pressure symptoms as a result of the compression of the structures around them. Common symptoms include generalized stomach pain, urological problems, gastrointestinal bleeding, and neurological symptoms such as leg paralysis or sciatica-like back pain. Rarely, they may exhibit hemodynamic instability together with an aneurysm rupture, which has a high fatality rate. Due to the unique presentation, the diagnosis is typically rarely made and there is little experience with treating it. We report two cases of common iliac artery pseudoaneurysm found in two patients who had no notable medical history and who we chose to repair through the endovascular technique in the first case, an approach that has gained more ground for vascular repair worldwide, making it the current go-to method, and for the second case we chose a more traditional approach, through open surgery.

Patient-Level Meta-Analysis of Low-Dose Hydrocortisone in Adults with Septic Shock.

Low-Dose Hydrocortisone and Septic ShockCorticosteroids have been evaluated as a therapy for septic shock for more than 50 years. However, uncertainty persists about their effects on mortality. Pirracchio and colleagues undertake a patient-level meta-analysis to answer this important question.

Pulmonary Crohn's Disease or Crohn's Disease with Lung Sarcoidosis? A Case Report and Literature Review.

BACKGROUND: Crohn's disease and ulcerative hemorrhagic colitis are forms of granulomatous inflammatory intestinal disease, which usually affects the gastrointestinal tract. There are also reported rare localizations at the skin, kidney, joints, liver and eye level. Pulmonary involvement is relatively rare, and it is most commonly reported in suppuration with bronchiectasis. On the other hand, sarcoidosis is, in principle, a thoracic localization of a granulomatosis disease, although bowel, skin and intestinal disorders are described. There is not a clear line to separate Crohn's disease from sarcoidosis with, possibly because they are, in fact, considered to have the same inflammatory granulomatosis disease pathology. The diagnoses of the two entities, sarcoidosis and Crohn's disease, are based on non-pathognomonic, inclusive clinical and paraclinical criteria, without elements of the mutual exclusion of typical locations. CASE REPORT: We present a very rare case of a young male, already diagnosed with small-bowel Crohn's disease. Granulomatous lung disease with major hemoptysis requires emergency surgery. An intraoperative assessment revealed a necrotic hemorrhagic lesion located in the left lower lobe and a lobectomy was performed. The final pathological report showed the presence of non-caseous granulomatous inflammation, with the identification of specific multinucleated giant cells. CONCLUSIONS: The identical diagnostic principles of Crohn's disease and sarcoidosis, Crohn's disease as a predecessor to pulmonary lesions, the clinical picture and the necrotico-hemorrhagic appearance of the unilateral pulmonary lesion, which are similar to aggressive necrotico-hemorrhagic or perforating intestinal forms, are arguments in favor of the diagnosis of pulmonary Crohn's disease and not pulmonary sarcoidosis. At the same time, in general, the two diseases have overlapping elements, suggesting they are, in fact, not the same disease with different facets.

Toxic-Induced Nonthyroidal Illness Syndrome Induced by Acute Low-Dose Pesticides Exposure-Preliminary In Vivo Study.

BACKGROUND AND OBJECTIVES: Conditions such as trauma, burns, sepsis, or acute intoxications have considerable consequences on the endocrine status, causing "sick euthyroid syndrome". Organophosphate exposure may induce an increase in acetylcholine levels, thus altering the thyroid's hormonal status. The present study aims to identify the effects of acetylcholinesterase inhibition on thyroid hormones. MATERIAL AND METHODS: A prospective experimental study was conducted on twenty Wistar rats. Blood samples were drawn to set baseline values for thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4). Chlorpyrifos 0.1 mg/kg was administered by oral gavage to induce acetyl-cholinesterase inhibition. After exhibiting cholinergic symptoms, blood samples were collected to assess levels of cholinesterase and thyroid hormones using ELISA. RESULTS: Butyrylcholinesterase levels confirmed major inhibition immediately after intoxication compared to the baseline, certifying the intoxication. A significant increase in T4 levels was noted (p = 0.01) both at 2 h and 48 h after administration of organophosphate in sample rats. Similarly, T3 almost doubled its value 2 h after poisoning (4.2 ng/mL versus 2.5 ng/mL at baseline). Surprisingly, TSH displayed acute elevation with an afterward slow descending trend at 48 h (p = 0.1), reaching baseline value. CONCLUSIONS: This study demonstrated that cholinesterase inhibition caused major alterations in thyroid hormone levels, which may be characterized by a transient hypothyroidism status with an impact on survival prognosis.

Cervical intranodal schwannoma - a rare diagnosis.

Intranodal schwannoma is a rare benign tumor, which originates from the peripheral nerve sheath (Schwann cells), fewer cases being reported with lymphatic involvement. We present the case of a middle-aged female patient, with one-year growing mass in the lateral-cervical area, in intimate relation with the vascular package of the neck. Preoperative cervical computed tomography examination showed the tumor features. There was no intraoperative complication, with the piece being completely removed. The morphological examination revealed the structure of a lymph node, and after Hematoxylin-Eosin staining, there were eosinophilic cytoplasm, euchromatic nuclei, with round, elongated or slightly wavy form and reduced pleomorphism, rare degenerative nuclear atypia, and no mitotic activity nor necrosis. The expression of S100 protein on immunohistochemistry, along with negative results for smooth muscle actin and desmin sustained the diagnosis of intranodal schwannoma of the neck. With a low index of cellular proliferation (Ki67), this case is in line with the reported features of schwannoma having extremely rare malignant transformation.

Hemorrhagic Cardiac Tamponade-An Unusual Threat in the COVID-19 Recovery Phase.

Cardiac tamponade is a rare presentation in patients with COVID-19, which may be induced by the associated exacerbated inflammatory response. The onset of cardiac tamponade may be concomitant with the acute phase of the disease or may develop subsequently as a new health condition secondary to the disease. We report four cases of cardiac tamponade that occurred late after the acute phase of the disease. One of them may be considered a post-acute complication of the disease, and three of them may be classified as a new health condition induced by COVID-19. Only two cases had a history of severe respiratory distress due to COVID-19. In all four cases, pericardiocentesis was imposed, and surprisingly, in every case, hemorrhagic fluid was evacuated. In this case, series, immune-mediated etiology is supported by histopathological results, where the main identified feature was fibrous pericarditis with inflammatory infiltrate. Only one patient included in this report died, and three of them were discharged after anti-inflammatory treatment was initiated.

The Importance of Iron Administration in Correcting Anaemia After Major Surgery.

INTRODUCTION: Postoperative anaemia can affect more than 90% of patients undergoing major surgeries. Patients develop an absolute iron deficiency in the face of significant blood loss or preoperative anaemia and major surgery. Studies have shown the negative impact of these factors on transfusion requirements, infections, increased hospitalisation and long-term morbidities. AIM OF THE STUDY: The research was performed to determine the correlation between intravenous iron administration in the postoperative period and improved haemoglobin correction trend. MATERIAL AND METHODS: A prospective study was conducted to screen and treat iron deficiency in patients undergoing major surgery associated with significant bleeding. For iron deficiency anaemia screening, in the postoperative period, the following bioumoral parameters were assessed: haemoglobin, serum iron, transferrin saturation (TSAT), and ferritin, direct serum total iron-binding capacity (dTIBC), mean corpuscular volume (MCV) and mean corpuscular haemoglobin (MCH). In addition, serum glucose, fibrinogen, urea, creatinine and lactate values were also collected. RESULTS: Twenty-one patients undergoing major surgeries (52,38% were emergency and 47,61% elective interventions) were included in the study. Iron deficiency, as defined by ferritin 100-300 µg/L along with transferrin saturation (TSAT) < 20 %, mean corpuscular volume (MVC) < 92 fL, mean corpuscular haemoglobin (MCH) < 33 g/dL, serum iron < 10 µmol/L and direct serum total iron-binding capacity (dTIBC) > 36 µmol/L, was identified in all cases. To correct the deficit and optimise the haematological status, all patients received intravenous ferric carboxymaltose (500-1000 mg, single dose). Using Quadratic statistical analysis, the trend of haemoglobin correction was found to be a favourable one. CONCLUSION: The administration of intravenous ferric carboxymaltose in the postoperative period showed the beneficial effect of this type of intervention on the haemoglobin correction trend in these groups of patients.

The prevalence and the impact of sarcopenia in digestive cancers. A systematic review.

Introduction: Sarcopenia is characterized by a decrease in skeletal muscle mass, associated with low muscle strength and/or poor physical performance. Assessing the prevalence of sarcopenia among digestive cancers and establishing the impact that sarcopenia has on the postoperative evolution of digestive tumors may be a central pillar in improving postoperative outcomes by caring for perioperative sarcopenia. This brief review aimed to evaluate the prevalence of sarcopenia in digestive cancer patients. Method and materials: PubMed database was searched for "sarcopenia" AND "digestive cancers" from January 1st, 2010, through September 30th, 2020. PRISMA guideline was used for this systematic review. After the selection process, 31 complete studies were included in our review. Assessment of sarcopenia diagnosis for the studies included in this systematic review was based on a computed tomographic calculation of the skeletal muscle index at the third lumbar vertebra. Results: Among a total of 11,651 patients with digestive cancers, the prevalence of sarcopenia was 43.68%. The highest prevalence of sarcopenic patients was in esophageal (70.4%) and hepatic (60.3%) cancer, following by biliary tract (49.3%), pancreatic (45.70%), colorectal (42.83%) cancer, and gastric cancer (32.05%) with the lowest prevalence. The results of the studies conducted by now regarding the prevalence of sarcopenia in digestive cancers and its relevance in the evolution of these cancers are discordant and uneven. Some studies show that the presence of sarcopenia in patients with digestive cancers is associated with an increased rate of postoperative complications, increased toxicity of chemotherapeutics and increased mortality. Other studies do not find sarcopenia as an independent risk factor associated with negative consequences in the course of patients with digestive cancers. Conclusions: Sarcopenia is prevalent in digestive cancers. There is still no consensus about the impact of sarcopenia on the treatment of digestive cancers. Further studies are needed to evaluate the real consequences of sarcopenia in digestive cancers..

Rhabdomyolysis-Induced Acute Renal Injury in a Schizophrenic Patient.

Nowadays, schizophrenia is treated with atypical antipsychotics that can determine neuroleptic malignant syndrome or rhabdomyolysis appearance. In addition to trauma and muscular hypoxia, there are some drugs and toxins associated with rhabdomyolysis development, among which olanzapine. A case of severe rhabdomyolysis syndrome, with extremely high levels of serum creatine kinase (CK), followed by acute kidney failure, secondary to olanzapine overdose and prolonged immobilization is outlined. Continuous renal replacement therapy was performed, with a slow clearance of serum CK levels. Under supportive therapy, systemic alkalinisation with volume resuscitation and corticotherapy, patient's general condition was improved, as well as his lower limb paresis. He followed frequent psychiatric evaluations and psychotherapies, before and after being transferred to a medical service. Rhabdomyolysis diagnosis is difficult in mild cases due to non-specific signs and symptoms, but it also has some typical manifestation, generically called "the rhabdomyolysis syndrome triad". The treatment is usually supportive; renal replacement therapy is required in the presence of acute kidney injury unresponsive to aggressive volume resuscitation. The systemic myoglobin release is responsible for renal injury. Olanzapine muscle toxicity can lead to severe rhabdomyolysis syndrome complicated with acute kidney injury and multiple organ dysfunction syndrome. Rapid identification and aggressive therapeutic management are essential for improving patients' outcome and prevent the occurrence of irreversible injuries.

Non-Hodgkin's lymphoma, rare localization at the base of the tongue - case presentation.

The extranodal malignant lymphomas occur mainly in the region of the head and neck, after the gastrointestinal tract. The most common site of the head and neck lymphoma is at the lymphatics ring of Waldeyer, followed by the nasosinusal region. Localization at the base of the tongue is extremely rare. The authors reported a case of a 50-year-old male with a non-Hodgkin's lymphoma, which developed at the base of tongue. An unusual sensation described as a foreign body at the hypopharyngeal region associated with progressive dysphagia were the main symptoms for which the patient was referred to our Hospital. The fibroscopic exam has revealed an oval tumor of the base of tongue, with large dimensions, sessile emergent base and smooth superficial mucosa. The tumor was removed using an endoscopic transoral approach, followed by the histopathological and immunohistochemical examination, which have been suggestive for non-Hodgkin's lymphoma with small B-cells. The treatment continued with chemotherapy, while radiotherapy was not necessary due to the fact that the tumor was completely removed.

Perioperative Patient Blood Management Programme. Multidisciplinary recommendations from the Patient Blood Management Initiative Group.

Patients with untreated anaemia or iron deficiency who undergo surgical procedures have an increased risk for mortality and morbidity. Patient Blood Management programmes address this issue worldwide and try to improve patient outcomes through a complex set of measures targeting anaemia correction, minimisation of bleeding and improvement of anaemia tolerance, in all phases of perioperative care. The Patient Blood Management Initiative Group is a multidisciplinary team of physicians from specialties including anaesthesiology, nephrology, surgery, orthopaedics, haematology, gastroenterology and transfusion medicine. The team has elaborated ten recommendations, divided into five categories, in order to implement a Patient Blood Management programme in Romania, using the most recent and relevant evidence. The document was discussed during three meetings which took place during October 2016 and May 2017 and the result was modified and updated via e-mail.

Metastatic high-grade myxofibrosarcoma: review of a clinical case.

We present the particular clinical and histological features of a metastatic high-grade myxofibrosarcoma (MFS) of the left buttock in a 77-year-old male patient. The tumor was biopsied and surgically removed in order to increase the patient's comfort, due to its increased size and aggressive clinical behavior. Computed tomography (CT) revealed metastases in the pleura and mediastinal lymph nodes, so limb-sparing tumor excision followed by palliative care was the best practice for the patient until the fatal outcome. The histological assessment revealed a tumor composed partly of solid sheets of spindled and pleomorphic cells, partly of areas with prominent myxoid matrix and numerous elongated capillaries. Mitotic figures are frequent, often atypical, followed by numerous giant cells with abundant eosinophilic elongated cytoplasm, resembling myoid cells often multinucleated. A panel of immunohistochemical stainings, including muscle-specific actin (MSA), S-100, CD34, desmin and myogenin were performed with a negative result, which aided excluding other soft tissue tumors like rhabdomyosarcoma and leiomyosarcomas, while Ki-67 was highly expressed in more than 70% of the tumor cells. This tumor received 6 points in accordance with the Fédération Nationale des Centres de Lutte Contre le Cancer (modified FNCLCC) and was defined as a high-grade MFS [stage IV, G3 pT2bN0M1, according to the 8th edition of TNM Classification of Malignant Tumors, ICD-O 8811÷3 in World Health Organization (WHO) Classification 2013]. Due to the clinical findings combined with the histological profile, the fatal prognosis was expected, though the time period was shorter than predicted, confirming the aggressive nature of the tumor. Even if traditionally was considered MFS as a non-metastatic lesion, recent case reports and studies, including our case revealed that this tumors in fact have the potential to be fatal due to metastatic disease.

The influence of parenteral glutamine supplementation on glucose homeostasis in critically ill polytrauma patients--A randomized-controlled clinical study.

BACKGROUND & AIMS: Rapid onset of resistance to insulin is a prominent component of stress metabolism in multiple trauma patients. Recent studies have clarified the role of amino acids (especially glutamine) in glucose transportation and the benefits of parenteral alanyl-glutamine supplementation (0.3-0.6 g/kg/day) in glucose homeostasis. The aims of this study are to evaluate the incidence of hyperglycemic episodes and the need for exogenous insulin to maintain stable glucose levels in critically ill polytrauma patients supplemented with parenteral glutamine dipeptide (Dipeptiven(®)) versus standard nutritional support. METHODS: This was an open-label randomized-controlled trial of 82 polytrauma patients aged 20-60 years old, randomly assigned into two equal groups independent of sex, age and Injury Severity Score. We excluded patients with diabetes mellitus, or renal or hepatic failure. One group received parenteral Dipeptiven(®) supplementation of 0.5 g/kg/day and the other received standard isocaloric isoproteinic nutritional support. RESULTS: We found that 63% of patients in the glutamine-supplemented group had no hyperglycemic episodes; only 37% required exogenous insulin (mean daily requirement of 44 units/day). In the control group, 51% of patients required insulin (mean daily requirement 63 unit/day; p = 0.0407). CONCLUSIONS: The effect of glutamine supplementation on glucose homeostasis is associated with a lower incidence of hyperglycemia among critically ill polytrauma patients, and leads to a lower mean daily dose of insulin. Controlled-trials.com Identifier: ISRCTN71592366 (http://www.controlled-trials.com/ISRCTN71592366/ISRCTN71592366).

[Activated recombinant factor VII (Novoseven) in multiple trauma patients: an outcome analysis]. / Utilizarea factorului VII activat recombinat (Novoseven) la pacientii politraumatizati: analiza evolutiei si prognosticului.

BACKGROUND AND OBJECTIVE: In multiple trauma patient the bleeding is a major cause of death and it is caused by vascular injury or post-traumatic coagulopathy. Regardless of etiology, management of massive bleeding requires immediate surgery to stop bleeding with simultaneous stabilization of hemostasis and maintenance of normovolemia. The objective was to evaluate the efficacity and safety of recombinant activated factor VII in patients with massive posttraumatic hemorrhage after failure of conventional methods to control bleeding (surgical haemostasis, volemic resuscitation, transfusions, rewarming). METHODS: 34 multiple trauma patients with severe hemorrhage requiring > 10 transfusion units of packed red cells received recombinant activated factor VII. Postdrug transfusion requirements were assessed (red packed cells, fresh frozen plasma, platelet concentrations and cryoprecipitate), and mortality was compared with predicted outcomes, using Injury Severity Score, Revised Trauma Score and Trauma Score-Injury Severity Score. We also noted the incidence of adverse effects, mostly thromboembolic events. We use a special design chart to follow the patients who received rFVIIa. RESULTS: We have the following results: the mortality rate was reduced (without statistical relevance), the coagulation times also reduced--aPTT decreases from 76 s to 38.5 (p = 0.000), PT from 23 s to 18 s (p = 0.000), transfusion requirements decrease- RPCs from 11.5 units to 3 units (p = 0.000), FFP from 7.5 units to 2 units (p = 0.000). We analysed the cases with adverse effects but we didn't find a direct cause- effect explication. CONCLUSIONS: The rFVIIa is efficient in post-trauma-tic bleeding (decrease transfusion requirements, normalized coagulation times), reduce mortality rate.