Massive Blood Transfusion in Patients with Ruptured Abdominal Aortic Aneurysm.

OBJECTIVES: The aim was to study blood transfusions and blood product ratios in massively transfused patients treated for ruptured abdominal aortic aneurysms (rAAAs). METHODS: This was a registry based cohort study of rAAA patients repaired at three major vascular centres between 2008 and 2013. Data were collected from the Swedish Vascular Registry, hospitals medical records, and local transfusion registries. The transfusion data were analysed for the first 24 h of treatment. Massive transfusion (MT) was defined as 4 or more units of red blood cell (RBC) transfused within 1 h, or 10 or more RBC units within 24 h. Logistic regression was used to calculate the odds ratio of 30 day mortality associated with the ratios of blood products and timing of first units of platelets (PLTs) and fresh frozen plasma (FFP) transfused. RESULTS: Three hundred sixty nine rAAA patients were included: 80% men; 173 endovascular aneurysm repairs (EVARs) and 196 open repairs (ORs) with median RBC transfusion 8 units (Q1-Q3, 4-14) and 14 units (Q1-Q3, 8-28), respectively. A total of 261 (71%) patients required MT. EVAR patients with MT (n = 96) required less transfusion than OR patients (n = 165): median RBC 10 units (Q1-Q3, 6-16.5) vs. 15 units (Q1-Q3, 9-26) (p = .002), FFP 6 units (Q1-Q3, 2-14.5) vs. 13 units (Q1-Q3, 7-24) (p < .001), and PLT 0 units (Q1-Q3, 0-2) vs. 2 units (Q1-Q3, 0-4) (p = .01). Median blood product ratios in MT patients were FFP/RBC (EVAR group 0.59 [0.33-0.86], OR group 0.84 [0.67-1.2]; p < .001], and PLT/RBC (EVAR 0 [0-0.17], OR 0.12 (0-0.18); p < .001]. In patients repaired by OR a FFP/RBC ratio close to 1 was associated with reduced 30 day mortality (p = .003). The median PLT/RBC ratio was higher during the later part of the study period (p < .001, median test), whereas there was no significant difference in median FFP/RBC ratio (p = .101, median test). CONCLUSION: The majority of rAAA patients undergoing EVAR required MT. EVAR patients treated with MT had lower FFP/RBC and PLT/RBC ratios than OR patients with MT. The mortality risk was lower with FFP/RBC ratio close to 1:1 in open repaired patients requiring MT. The 24 h PLT/RBC ratio increased over the study period.

Safety of Intra-arterial Catheter Directed Thrombolysis: Does Level of Care Matter?

OBJECTIVES: The aim was to assess whether the level of care influenced the safety related outcomes of catheter directed thrombolysis (CDT) for patients presenting with limb ischaemia and dialysis access thrombosis. METHODS: This was a retrospective cohort study. All consecutive patients at two tertiary referral centres for vascular surgery undergoing CDT for limb ischaemia and dialysis access thrombosis (N = 252) between 2012 and 2014 were included. Patients at Centre 1 were cared for on a general vascular ward and patients at Centre 2 were kept on a post-operative recovery unit with an increased level of care including invasive haemodynamic monitoring. Patient medical records were retrospectively scrutinised and data collected on comorbidities, anti-thrombotic medication, indications for CDT, technical success of CDT, bleeding and non-bleeding related complications, and transfer to a higher level of care. RESULTS: There were no differences in the frequency of non-bleeding related complications between Centre 1 and Centre 2. Patients on the vascular ward had a higher frequency of minor bleeding (p = .002) but there was no difference in major bleeding (p = .12). Eleven patients on the ward required an increased level of care for medical reasons and six were moved for a lack of resources. The presence of cardiac disease was an independent risk factor for patient transfer (OR 3.2; 95% CI 1.04-9.8, p = .04). CONCLUSIONS: CDT may be undertaken outside of a high dependency setting without a significantly increased risk of complications. Pre-existing cardiac disease was an independent risk factor for transfer to a higher level of care. These findings could have an implication for the clinical cost-effectiveness of CDT.

Development and evaluation of a new simulation model for interactive training of the medical response to major incidents and disasters.

BACKGROUND AND AIMS: The need for and benefit of simulation models for interactive training of the response to major incidents and disasters has been increasingly recognized during recent years. One of the advantages with such models is that all components of the chain of response can be trained simultaneously. This includes the important communication/coordination between different units, which has been reported as the most common cause of failure. Very few of the presently available simulation models have been suitable for the simultaneous training of decision-making on all levels of the response. In this study, a new simulation model, originally developed for the scientific evaluation of methodology, was adapted to and developed for the postgraduate courses in Medical Response to Major Incidents (MRMI) organized under the auspices of the European Society for Trauma and Emergency Surgery (ESTES). The aim of the present study was to describe this development process, the model it resulted in, and the evaluation of this model. METHODS: The simulation model was based on casualty cards giving all information normally available for the triage and primary management of traumatized patients. The condition of the patients could be changed by the instructor according to the time passed since the time of injury and treatments performed. Priority of the casualties as well as given treatments could be indicated on the cards by movable markers, which also gave the time required for every treatment. The exercises were run with real consumption of time and resources for all measures performed. The magnetized cards were moved by the trainees through the scene, through the transport lines, and through the hospitals where all functions were trained. For every patient was given the definitive diagnosis and the times within certain treatments had to be done to avoid preventable mortality and complications, which could be related to trauma-scores. RESULTS: The methodology was tested in nine MRMI courses with a total of 470 participants. Based on continuous evaluations and accumulated experience, the setup of the simulation was step-wise adjusted to the present model, including also collaborating agencies such as fire and rescue services as well as the police, both on-scene and on superior command levels. The accuracy of the simulation cards for this purpose was evaluated as "very good" by 63 % of the trainees and as "good" by 33 %, the highest two of the six given alternatives. The participants' ranking of the extent that the course increased their competencies related to the given objectives on a 1-5 scale for prehospital staff had an average value of 4.25 ± 0.77 and that for hospital staff had an average value of 4.25 ± 0.72. The accuracy of the course for the training of major incident response on a 1-5 scale by prehospital staff was evaluated as 4.35 ± 0.73 and that by hospital staff as 4.30 ± 0.74. CONCLUSIONS: The simulation system tested in this study could, with adjustments based on accumulated experience and evaluations, be developed into a tool for the training of major incident response meeting the specific demands on such training based on recent experiences from major incidents and disasters. Experienced trainees in several courses evaluated the methodology to be accurate for this training, markedly increasing their perceived knowledge and skills in fields of importance for a successful outcome of the response to a major incident.

Perioperative haemorrhage in endovascular abdominal aneurysm repair affects outcome.

OBJECTIVE: This study aimed to evaluate the outcome and predisposing factors related to perioperative bleeding in patients treated with endovascular aneurysm repair (EVAR) for ruptured and non-ruptured abdominal aortic aneurysm (AAA). DESIGN: This was a retrospective cohort study. METHODS: A total of 525 consecutive patients (73% elective) with AAA underwent EVAR at two vascular centres from 2008 to 2011. From registry data perioperative bleeding was analysed in relation to outcome and preoperative data. RESULTS: A total of 453 (86%) patients presented with a perioperative bleeding <1000 ml, 42 (8%) patients 1000-1999 ml, 19 (4%) patients 2000-5000 ml and 11 (2%) >5000 ml. Other than ruptured AAA (n = 90), no preoperative risk factors for increased perioperative bleeding were found. Open femoral artery access (n = 101), branched (n = 18) and uni-iliacal endografts (n = 18) and introducer size were associated with increased perioperative bleeding (P < 0.001). In multivariable logistic regression only rupture and perioperative bleeding >2000 ml were significantly related to 30-day mortality (odds ratio 10.6 (range 3.8-29.6) and 13.4 (range 4.8-37.4), respectively). Postoperative renal failure, multi-organ failure, >5 days at intensive care unit, bowel ischaemia and abdominal compartments syndrome were significantly related to perioperative bleeding >2000 ml (P < 0.001). CONCLUSION: Large perioperative bleeding during EVAR is a clinical problem that affects outcome. About 10% of elective AAA patients and 34% of patients with ruptured AAA, undergoing EVAR, present a perioperative blood loss exceeding 1 l. In our study, a perioperative blood loss exceeding 2 l was independently associated with increased mortality and morbidity in both acute and elective AAA patients. Open femoral access, branched EVAR and larger diameter introducers were associated with increased perioperative blood loss. ETHICAL APPLICATION: 2011/664-31/3 (approved).