Evaluation of fresh frozen plasma usage at a tertiary care hospital in North India

BACKGROUND: Concerns regarding transfusion-transmitted infections and non-availability of blood components in developing nations, make it crucial to optimize fresh frozen plasma (FFP) transfusions and reduce wastage. METHODS: A concurrent prospective study of FFP usage was carried out in a tertiary care hospital in north India. RESULTS: A total of 595 units were issued to 112 patients during the study period, of which 53 units (8.9%) were returned to the blood centre unused, leading to wastage. Appropriate indications for FFP usage were as per accepted British Council for Standardization in Haematology (BCSH) criteria. Among 112 patients 33 (29.5%) had had appropriate FFP transfusions (205 units) for indications that primarily included chronic liver disease, disseminated intravascular coagulopathy and prolonged bleeding with abnormal coagulation profile. Out of 33 patients with appropriate indications, 24 had abnormal coagulation profile but only half of these patients (n = 12) received adequate dose of FFP. Fresh frozen plasma was used for inappropriate indications in 79 patients (70.5%), which mainly included bleeding following cardiac surgery with normal coagulation test results, hypovolaemia and hypoproteinaemia. Such misuse was higher in surgical units than medical services (78 vs 45%). CONCLUSION: Fresh frozen plasma is grossly misused even in resource-deficient nations and immediate intervention is needed to stem the flow of this component. Physician education programmes and a monitoring system to ensure strict adherence to the established guidelines are required to reduce undue waste of this blood component.     

The use of fresh frozen plasma after major hepatic resection for colorectal metastasis: is there a standard for transfusion?

BACKGROUND: Major hepatic resection is indicated for selected patients with colorectal metastasis to the liver. Transfusion of fresh frozen plasma (FFP) might be required after major hepatectomy because of blood loss or coagulopathy, but there are no standard criteria for the use of FFP in this setting. METHODS: We identified 260 patients from our prospective database who underwent major (> or =3 Couinaud segments) hepatectomy between May 1997 and February 2001 for colorectal metastasis. FFP use was determined and tested for its relationship to clinical and pathologic factors. A survey on FFP use was sent to 12 other hepatobiliary centers worldwide. RESULTS: There were 142 (55%) men, 118 (45%) women, and the median age was 63 years. The most common hepatic resections performed were right lobectomy (37%) and extended right lobectomy (33%). There were 83 (32%) patients who received FFP. In these patients, a total of 405 units of FFP were administered with a median of 4 units. The majority of patients who received FFP were transfused within the first two postoperative days, while there were only five (2%) patients who initially received FFP beyond that time. FFP was administered for a median prothrombin time of 16.9. Only one (0.4%) patient required reoperation for bleeding. Right lobectomy and extended right lobectomy were found to predict FFP use on multivariate analysis. Postoperative complications did not correlate with FFP use. The criteria used for FFP administration at other major hepatobiliary centers were found to be variable. CONCLUSIONS: There is no universal standard for FFP use following major hepatic resection for colorectal metastasis. Our criterion of a prothrombin time of 16-18 seconds is conservative but results only rarely in reoperation for bleeding. Prospective evaluation of a higher threshold for FFP administration, such as an International Normal Ratio of 2.0, should be performed to better define the guidelines for FFP use in patients undergoing major hepatectomy who have normal underlying hepatic parenchyma.     

Perioperative management of factor XI deficiency in a patient undergoing hip arthroplasty

Factor XI deficiency, or hemophilia C, is a rare autosomal recessive bleeding disorder often diagnosed by inappropriate bleeding associated with trauma or a surgical procedure, and reports of anesthetic management of this disorder are rare. We experienced an 85-year-old man with femoral neck fracture who was diagnosed preoperatively with factor XI deficiency based on abnormally long activated partial thromboplastin time (APTT). He was scheduled for bipolar hip arthroplasty and was prepared for surgery by transfusion of fresh frozen plasma (FFP), instead of factor XI concentrates, which are not commercially available in Japan. Five units of FFP were transfused 6 days before surgery, and 10 units of FFP with 2 units of red concentrated cells (RCC) were used on the day of surgery. Transfusion of FFP shortened the APTT to a level sufficient to allow hemostasis, although not to within the normal range. Although the patient required transfusion of 2 units of RCC postoperatively, no bleeding complications occurred. For bipolar hip arthroplasty, transfusion of FFP produced sufficient hemostasis without the use of tranexamic acid, factor VII preparations, or desmopressin.     

The safety of percutaneous tracheostomy in patients with coagulopathy or thrombocytopenia

The safety and complications of percutaneous tracheostomy (PT) without bronchoscopic guidance in a group of ICU patients with thrombocytopenia platelet count of < or = 60.000/mm3) or coagulopathy (INR > or = 1.5 or systemic heparinization), was studied. During the study period (May 2004-June 2005), 190 percutaneous tracheostomies were performed. Of these there were 11 (6%) patients with prolonged INR, 7 (4%) patients with thrombocytopenia and 14 (7%) patients on systemic heparin. There was no evidence of bleeding in patients with prolonged INR. A minor bleeding developed in only one patient with thrombocytopenia, and in two patients receiving systemic heparin. The PT was aborted for one patient with thrombocytopenia and slight increase of INR (1.3) due to major bleeding in spite of transfusion of both platelets and FFP. Our data suggest the incidence of bleeding is low in patients with coagulopathy and or thrombocytopenia-undergoing PT without bronchoscopic guidance.     

Use of recombinant factor VIIa for uncontrolled bleeding in neonates after cardiopulmonary bypass

Background:  Increasingly, recombinant activated factor VII (rFVIIa) is used adjunctively in nonhemophiliacs to control hemorrhage unresponsive to conventional therapy in a variety of settings including postcardiopulmonary bypass (CPB). Studies examining rFVIIa administration to neonates after CPB are limited. The goal of this study was to evaluate retrospectively the clinical outcomes of neonates treated at our institution with rFVIIa for uncontrolled post-CPB bleeding.
Methods:  We retrospectively identified eight neonates undergoing complex congenital cardiac surgery who received rFVIIa, either intraoperatively or postoperatively, for uncontrolled post-CPB bleeding. Transfusion trends and prothrombin times (PT) were assessed both pre- and post-rFVIIa administration. Chest tube drainage volumes were recorded pre- and post-rFVIIa administration in those neonates receiving rFVIIa postoperatively in the intensive care unit. We documented such adverse events as thrombosis, dialysis (hemodialysis and peritoneal dialysis), extracorporeal membrane oxygenation (ECMO) and in-hospital mortality.
Results:  The mean amount of transfused packed red blood cells, platelets and fresh frozen plasma decreased significantly after the administration of rFVIIa. Transfusion of cryoprecipitate trended towards a decrease but did not reach statistical significance. PT values also decreased significantly after the administration of rFVIIa. A high mortality was found in neonates exposed to both rFVIIa and ECMO; however, this was not significantly different from the mortality of neonates exposed to ECMO alone.
Conclusions:  Administration of rFVIIa to neonates for the treatment of uncontrolled post-CPB bleeding significantly reduced transfusion requirements and normalized PT values. Future randomized, controlled trials are needed to evaluate the potential hemostatic benefit and adverse effects of rFVIIa administration to neonates following CPB.     

Platelet-rich plasma sequestration, with therapeutic platelet yields, reduces allogeneic transfusion in complex cardiac surgery

Platelet dysfunction is the most common cause of nonsurgical bleeding after cardiopulmonary bypass (CPB). We hypothesized that reinfusion of a therapeutic quantity of platelets sequestered before CPB would decrease the need for allogeneic platelet transfusion, as well as decrease bleeding and total allogeneic transfusion, in cardiac surgery patients at moderately high risk for bleeding. Fifty-five patients undergoing either reoperative coronary artery bypass (CABG) or combined CABG and valve replacement were randomized to control or platelet-rich plasma sequestration (pheresis) groups. All patients received intraoperative epsilon-aminocaproic acid infusions. There was no significant difference between groups with respect to preoperative characteristics, duration of CPB, or target postoperative hematocrit. Mean platelet yields were 6.2 +/- 2.1 units (3.1 x 10(11) platelets). Mean pheresis time was 44 min. Allogeneic platelets (range = 6-12 units) were transfused to 28% of control patients, compared with 0% of pheresis patients (P < 0.01). Allogeneic packed red blood cells were transfused to 45% of control patients (1.2 units per patient) versus 31% of pheresis patients (0. 7 unit per patient) (P = 0.35). Total allogeneic units transfused were significantly reduced in the pheresis group (P < 0.02). Mediastinal chest tube drainage was not significantly decreased in the pheresis group. In this prospective, randomized study, therapeutic platelet yields were obtained before CPB. In contrast with recent studies with low platelet yields, these data support the conclusion that platelet-rich plasma sequestration is effective in reducing allogeneic platelet transfusions and total allogeneic units transfused in cardiac surgery patients at moderately high risk for post-CPB coagulopathy and bleeding. IMPLICATIONS: Transfusion of allogeneic blood products, including platelets, is common during complex cardiac surgical procedures. In the present prospective, randomized study, a significant reduction in allogeneic platelet transfusion and total allogeneic units transfused was observed after the reinfusion of a therapeutic quantity of autologous platelets sequestered before cardiopulmonary bypass.     

Randomized, Placebo-Controlled, Double-Blind Study of an Ultra-Low-Dose Aprotinin Regimen in Reoperative and/or Complex Cardiac Operations

A bstract Background and aim of the study : High-dose aprotinin is an effective but costly method to reduce transfusions after cardiopulmonary bypass (CPB). Very low doses of aprotinin have been shown to be effective in primary cardiac surgery, but not in patients undergoing procedures associated with the greatest usage of allogeneic blood products after CPB. We evaluated the efficacy of ultra-low-dose aprotinin in this patient population. Methods : Aprotinin 1 million KIU or placebo was added to the priming solution of the CPB circuit of 52 patients undergoing a reoperation and/or a complex surgical procedure. Dryness of operative field, hemoglobin concentrations, coagulation parameters, chest drainage, and transfusion requirements were compared. Results : Total chest drainage was not different between groups, but fewer patients in the aprotinin group required additional protamine postoperatively (35% vs 69% for controls, p = 0.03) and fewer received fresh frozen plasma (FFP; 19% vs 46% for controls, p = 0.04). Red cell transfusion was smaller in the aprotinin group compared to placebo (median 4 and 2 units, respectively, p = 0.04). Transfusion of FFP, platelets, cryoprecipitates was not different between groups. Total number of units transfused tended to be reduced in the aprotinin group compared to control (median 2 and 7 units, respectively, p = 0.06). Conclusions : Prophylactic administration of ultra-low-dose aprotinin reduced transfusions in patients undergoing repeat operations or complex procedures. Aprotinin could be used in a more economical manner, even in this patient population at high-risk of receiving allogeneic blood products.     

A mathematical model for fresh frozen plasma transfusion strategies during major trauma resuscitation with ongoing hemorrhage.

BACKGROUND: Randomized controlled trials of how best to administer fresh frozen plasma (FFP) in the presence of ongoing severe traumatic hemorrhage are difficult to execute and have not been published. Meanwhile, coagulopathy remains a common occurrence during major trauma resuscitation and hemorrhage remains a major cause of traumatic deaths, suggesting that current coagulation factor replacement practices may be inadequate. METHODS: We used a pharmacokinetic model to simulate the dilutional component of coagulopathy during hemorrhage and compared different FFP transfusion strategies for the prevention or correction, or both, of dilutional coagulopathy. Assuming the rates of volume replacement and loss are roughly equal, we derived the hematocrit and plasma coagulation factor concentration over time based on the rate of blood loss and replacement, the hematocrit and coagulation factor concentration of the transfusate, and the hematocrit and plasma factor concentration at the time when FFP transfusion begins. RESULTS: Once excessive deficiency of factors has developed and bleeding is unabated, 1-1.5 units of FFP must be given for every unit of packed red blood cells (PRBC) transfused. If FFP transfusion should start before plasma factor concentration drops below 50% of normal, an FFP:PRBC transfusion ratio of 1:1 would prevent further dilution. CONCLUSION: During resuscitation of a patient who has undergone major trauma, the equivalent of whole-blood transfusion is required to correct or prevent dilutional coagulopathy.     

Strategies for transfusion therapy

Transfusion of allogeneic red blood cells (RBCs), fresh frozen plasma (FFP) and platelets is associated with risks, and outcome studies comparing liberal and restrictive transfusion regimens are lacking in surgical patients. Therefore, guidelines have been established. They recommend first maintaining normovolaemia by the use of crystalloids and colloids. RBC transfusions are recommended for haemoglobin levels <6 g/dl and for physiological signs of inadequate oxygenation such as haemodynamic instability, oxygen extraction>50% and myocardial ischaemia (new ST-segment depressions >0.1 mV, new ST-segment elevations >0.2 mV or new wall motion abnormalities in transoesophageal echocardiography). FFP transfusions are recommended for urgent reversal of anticoagulation, known coagulation factor deficiencies, microvascular bleeding in the presence of elevated (>1.5 times normal) prothrombin time (PT) or partial thromboplastin time (PTT) and microvascular bleeding after the replacement of more than one blood volume when PT or PTT cannot be obtained. Platelet transfusions are recommended prior to major operations in patients with platelet counts <50 000/μl, intraoperatively with microvascular bleeding at platelet counts <50 000/μl and in the range of 50 000–100 000/μl following cardiopulmonary bypass and in patients undergoing surgery where already minimal bleeding may cause major damage such as in neurosurgery.     

Percutaneous dilatational tracheotomy in intensive care unit patients with increased bleeding risk or obesity. A prospective analysis of 1000 procedures

Background: Percutaneous dilatational tracheotomy (PT) is safe and cost effective, and has become a routine method in intensive care units (ICU), but safety concerns persist for obese patients and for patients with a high risk of bleeding. In this prospective study of 1000 PTs, we have investigated whether such patient characteristics were associated with an increased procedural risk. Methods: We prospectively recorded all PTs performed in our ICU from 2001 to 2009. Data on blood transfusion were entered from a central database. The association of risk factors with bleeding and other complications was analysed with logistic regression. Results: The total number of PTs and surgical tracheotomies was 1.454. The median number of days on a ventilator until PT was 6 in 2001, decreasing to 3 in 2009. A procedure‐related complication was reported in 17.5%. There was no PT‐related mortality. The rate of potentially life‐threatening complications was 1.2%. Three patients developed pneumothorax and one of these had circulatory arrest and was successfully resuscitated. Three hundred and twelve patients had one or more units of blood transfused, but only 19 (1.9%) were PT related. Increased INR was the most important risk factor for bleeding [odds ratio (OR) 2.99], followed by low platelets (OR 1.99). The rate of complications in patients with high body mass index was not increased. Conclusion: PT is a safe procedure that can be performed with a low complication rate in patients with increased risk of bleeding as well as in obese patients.     

Problems with 20 or more blood transfusions in 24 hours

The case records of 128 patients receiving 129 transfusions of 20 or more units of blood within a 24-hour period at Detroit Receiving Hospital, between August 1980 and August 1985, were reviewed. In patients receiving 20 to 49 units of blood, without pre-existing disease or prolonged shock, the mortality rate was 36 per cent (15/42). In similar patients who had prolonged shock, the mortality rate was 61 per cent (27/44). If the patient had pre-existing disease and prolonged shock, the mortality rate with 20 to 49 units of blood was 92 per cent (12/13). All 13 patients receiving 50 or more units of blood died. Platelet counts were less than 50,000/microL in 50 per cent (51/102). The prothrombin time (PT) was prolonged by 5 or more seconds in 54 per cent (51/92). The partial thromboplastin time (PTT) was prolonged to more than 60 seconds in 45 per cent (42/94). There was no correlation between the PT, PTT, and amount of fresh frozen plasma (FFP) given. A coagulopathy was diagnosed clinically in 43 patients, but this did not correlate well with laboratory coagulation studies. The average core temperature of the patients was 32.9 +/- 1.7 C. Severe hypocalcemia with total calcium levels less than 6.0 mg/dL was found in 53 per cent (33/62). Ionized calcium levels Ca++ were less than 0.70 mmol/L in 56 per cent (24/43). Of the 82 deaths, 32 (38%) occurred in the operating room and 31 (38%) occurred within 48 hours from continued bleeding and/or shock. Twelve deaths (15%), from severe infections, occurred after 30 days.(ABSTRACT TRUNCATED AT 250 WORDS)     

A rapid platelet function assay used to regulate platelet transfusion prophylaxis following cardiopulmonary bypass surgery

Subsequent to cardiac surgery with cardiopulmonary bypass (CPB), patients are at risk of postoperative bleeding caused by acquired defects associated with the procedure. As such, many patients receive prophylactic blood product transfusion. The effectiveness of measuring platelet function using a near-patient platelet function analyzer for the purpose of regulating platelet transfusion and potentially modulating other blood products including fresh frozen plasma (FFP) and cryoprecipitate (CRYO) transfusion was evaluated prospectively in patients undergoing CPB. A 6-month prospective study was designed that encompassed all CPB patients at Aultman Hospital (Canton, OH) during 2001. Each patient was assessed postoperatively for platelet count and function using a point-of-care analyzer. Data were used to help determine whether a platelet transfusion would be administered. Transfusion of CRYO and FFP was also recorded. The data were then compared to the retrospective same 6-month period in the preceding year for the purpose of determining the value of this system in guiding transfusion triage. There were 1770 platelet packs transfused during the study period, representing a 34% reduction in platelet usage. Platelet transfusions were reduced by 51% (5.75 in 2001 vs. 11.75 in 2000) per patient. CRYO/FFP usage was also substantially reduced. During the study period, the patient caseload had increased by 72 (310 vs. 238). Monitoring platelet count and function as a result of CPB and administering an appropriate transfusion protocol can positively impact transfusion outcome.     

Experience of implementing a National pre-hospital Code Red bleeding protocol in Scotland

IntroductionThe Scottish Transfusion and Laboratory Support in Trauma Group (TLSTG) have introduced a unified National pre-hospital Code Red protocol. This paper reports the results of a study aiming to establish whether current pre-hospital Code Red activation criteria for trauma patients successfully predict need for in hospital transfusion or haemorrhagic death, the current admission coagulation profile and Concentrated Red Cell (CRC): Fresh Frozen Plasma (FFP) ratio being used, and whether use of the protocol leads to increased blood component discards?MethodsProspective cohort study. Clinical and transfusion leads for each of Scotland’s pre-hospital services and their receiving hospitals agreed to enter data into the study for all trauma patients for whom a pre-hospital Code Red was activated. Outcome data collected included survival 24 h after Code Red activation, survival to hospital discharge, death in the Emergency Department and death in hospital.ResultsBetween June 1 st 2013 and October 31 st 2015 there were 53 pre-hospital Code Red activations. Median Injury Severity Score (ISS) was 24 (IQR 14–37) and mortality 38%. 16 patients received pre-hospital blood. The pre-hospital Code Red protocol was sensitive for predicting transfusion or haemorrhagic death (89%). Sensitivity, specificity, positive and negative predictive values of the pre-hospital SBP <90 mmHg component were 63%, 33%, 86% and 12%. 19% had an admission prothrombin time >14 s and 27% had a fibrinogen <1.5 g/L. CRC: FFP ratios did not drop to below 2:1 until 150 min after arrival in the ED. 16 red cell units, 33 FFP and 6 platelets were discarded. This was not significantly increased compared to historical data.ConclusionsA National pre-hospital Code Red protocol is sensitive for predicting transfusion requirement in bleeding trauma patients and does not lead to increased blood component discards. A significant number of patients are coagulopathic and there is a need to improve CRC: FFP ratios and time to transfusion support especially FFP provision. Training clinicians to activate pre-hospital Code Red earlier during the pre-hospital phase may give blood bank more time to thaw and prepare FFP and may improve FFP administration times and ratios so long as components are used upon their availability.     

Hemostasis in massively transfused trauma patients.

Twenty-seven patients requiring massive transfusions were studied prospectively to determine whether administration of stored, modified whole blood induced a primary disorder of hemostasis evidenced by generalized microvascular oozing. Platelet counts fell in proportion to the number of units of blood transfused. In contrast, the levels of factors V and VIII correlated poorly with the units of blood transfused, 85% of the total variation in the levels being due to influences other than transfused blood. Levels of all other clotting factors were unrelated to the number of units of blood given. Eight patients developed abnormal bleeding. The cause appeared to be dilutional thrombocytopenia in five patients, and DIC in three. In six of the eight, bleeding was controlled with platelet concentrates alone. Two patients were given cryoprecipitate also. The most useful laboratory test for predicting abnormal bleeding was the platelet count. Fibrinogen levels should be followed as an aid in the diagnosis of DIC. The BT, PT, and PTT were not helpful in assessing the cause of bleeding, unless they were greater than 1.5 times the control value. We recommend that any patient receiving massive transfusions who develops diffuse microvascular bleeding be given platelet concentrates. Platelet counts as high as 100,000 may be required to control bleeding from surgical wounds. It is not necessary to supplement transfusions of stored, modified whole blood with fresh blood or fresh frozen plasma.     

Anesthetic management of a patient with blood coagulation factor XII deficiency]

A 36-yr-old pregnant woman with blood coagulation factor XII deficiency was scheduled to undergo cesarean section. Preoperative blood coagulation scan revealed prolonged activated partial thrombin time of 105.6 s (control, 30.3 s), and a decrease in factor XII level of 3% (normal; 70-120%). Other examinations such as prothrombin time, platelet count and bleeding time were within normal limits. But she reported no history of bleeding. Before the operation, we discussed with obstetricians whether fresh frozen plasma (FFP) should be administered, or not. According to a report, a patient with factor XII deficiency can undergo major surgery without plasma replacement therapy. But another study showed that 15-30% of the factor XII activity was needed for hemostasis. We, therefore, administered 4 units of fresh frozen plasma before the operation. The operation was performed with general anesthesia uneventfully. Generally, a patient with factor XII deficiency has no clinical bleeding problems and unnecessary FFP administration may cause infection. Therefore it is not necessary to administer FFP to this patient.     

Fresh-frozen plasma use in a South African tertiary hospital

Despite available guidelines on indications for fresh-frozen plasma (FFP) transfusion, inappropriate use is increasing worldwide. We evaluated FFP administration to patients admitted to the Steve Biko Academic Hospital over 4 months, including indications for use and completeness of requisition forms. Transfusions were considered inappropriate for 39.5% of units administered. Of request forms submitted, only 22% had sufficient information for the blood transfusion services of the indication for transfusion. Transfusion with FFP is a medical intervention that carries risks and should be undertaken with care. Although this study was conducted in one centre, it is evident that clinicians' lack of knowledge of the indications for administration of FFP is widespread. Intervention is necessary to improve patient outcomes and reduce expenditure.     

Perioperative blood transfusion: a plea for guidelines.

Red blood cells are still transfused inappropriately in spite of recent media attention and public awareness about the risks of blood products. A prospective audit was conducted to determine the avoidable blood transfusion rates in the elective perioperative setting utilising the guidelines issued by the American College of Physicians (ACP). Of 82 consecutive adult patients who were admitted for major elective surgery over a 3-month period, 28 were transfused a total of 94 units of homologous SAG-M blood, of which 50 (53%) were inappropriate as recommended by the ACP guidelines. Violations of the guidelines were perioperative transfusion in bleeding patients who were haemodynamically stable (31%) and transfusion in asymptomatic, stable patients solely to attain a haemoglobin level above 10 g% (22%). There is a need for objective, easily adaptable and widely disseminated consensus guidelines to the indications for red blood cell transfusion.     

Defining the need for blood and blood products transfusion following suicide bombing attacks on a civilian population: A level I single-centre experience

Introduction

Knowledge of patterns of blood use in the care of mass casualty settings is important for preparedness of medical centre resources and for maximising survival when blood supplies are limited. Our objectives were to review of our experience with the use of blood products and define the utilisation of blood transfusion following suicide bombing attacks.

Patients and methods

We conducted a retrospective analysis of blood and blood product transfusion following civilian bombing attacks at a level I trauma centre in Jerusalem, Israel from 2000 to 2005. The study group consisted of 137 patients who were admitted following 17 suicide bombing attacks which were carried out in Jerusalem during the 5-year period. Demographic data, number of units of blood and blood products transfused and the need for massive transfusions were recorded and analyzed.

Results

Fifty-three patients received blood transfusions (38.7%). There were 33 males (62.2%) with a median ISS of 13 (range 4–25). These 53 patients received 524 PRBC, 42 WB, and 449 FFP. The mean number of PRBC transfused/admitted patient was 3.82 units (range 0–59). Thirty patients (21.9%) received 236 PRBC (45% of total PRBC) at the first 2 h. The ratio of ordered to transfused blood was 946:524. The FFP:PRBC ratio for all transfused patients was 1:1.17. The number of PRBC transfused per attack correlated with the number of patients admitted per attack. The most commonly transfused blood type was A (52.3%). Only 18 units of uncrossed-matched blood were transfused (3.3% of total). 14 patients (10.2%) received massive transfusions. These patients received 399 PRBC (76.1% of total units transfused) and the average number of PRBC transfused was 28.5/patient (10–59).

Conclusions

More than 1/3 of casualties admitted following civilian bombing attacks received transfusions, most in the first 2 h. Large-scale attacks will require more blood and blood products than small-scale attacks. Twice the number of PRBC ordered than transfused reflects a known trend for over-triage during the initial assessment following bombing attacks. One tenth of patients received massive transfusion.     

Use of tranexamic acid in craniosynostosis surgery

BACKGROUND:

Intraoperative tranexamic acid (TXA) administration has been used to abate blood loss in a variety of surgical procedures. Several recent studies have supported its efficacy in reducing transfusion requirements in pediatric cranial vault reconstruction (CVR).

OBJECTIVE:

To conduct a retrospective chart review to determine whether a significant reduction in packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusions exists when TXA is used.

METHODS:

A retrospective cohort study of 28 patients who underwent CVR for sagittal craniosynostosis was performed. Transfusion requirements for 14 patients who did not receive TXA were compared with 14 patients who did. Predictors of increased blood product transfusion were also studied.

RESULTS:

Total volume of PRBC transfusion was reduced by 50% with the use of TXA (P=0.004) with a 34% reduction in intraoperative PRBC transfusion (P=0.017) and a 67% reduction in postoperative PRBC transfusion (P<0.001). Total volume of FFP transfusion was reduced by 46% (P=0.002) and postoperative FFP transfusion was reduced by 100% (P=0.001). The use of TXA was associated with a lower total volume of PRBC (P=0.003) and FFP (P=0.003) transfusions. Older patient age was associated with lower total volume of PRBC transfused (P=0.046 and P=0.002), but not with FFP (P=0.183 and P=0.099) transfusion volumes. Increasing patient weight was associated with lower PRBC (P=0.010 and P=0.020) and FFP (P=0.045 and P=0.016) transfusion volumes.

CONCLUSION:

TXA decreased blood product transfusion requirements in patients undergoing CVR for sagittal craniosynostosis, and should be a routine part of the strategy to reduce blood loss in these procedures.