乙肝肝衰竭患者临床输注新鲜冰冻血浆治疗效果分析

目的 回顾性调查分析乙肝肝衰竭患者临床输注新鲜冰冻血浆（fresh frozen plasma,FFP）的资料,了解输注FFP对于改善预后的疗效。方法 查阅2009-12/2013-07在四川省人民医院住院的88例乙肝肝衰竭患者,观察时间为4周,根据观察期间是否输注FFP分为2组,对照组31例未输注FFP,治疗组57例输注FFP,比较2组患者住院4周后和入院时的终末期肝病模型（Model for end-stage liver disease,MELD）评分,分析是否输注FFP和血浆用量对预后的影响,综合评估患者临床转归。结果 对照组MELD评分差值1.74±12.12,治疗组MELD评分差值-0.46±8.03,2组比较差异无统计学意义（t’=-0.91,P〉0.05）。治疗组的血浆用量和MELD评分差值使用直线相关分析,直线相关系数r=0.11 P〉0.05,无直线相关关系。结论 输注FFP不能改善乙肝肝衰竭患者的预后,不推荐预防性应用。     

Measurement of thrombin generation intra-operatively and its association with bleeding tendency after cardiac surgery

Introduction

Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) are susceptible to haemostatic disturbances. Monitoring the haemostatic capacity by conventional clotting tests is challenging.

Materials and Methods

Thrombin generation (TG) by Calibrated Automated Thrombography, clotting tests and tissue factor pathway inhibitor (TFPI) measurements were performed to describe the relationship between haemostatic changes and alterations in these tests. Blood samples were collected before, during and after CPB. Furthermore, it was investigated whether TG measured intraoperatively, is associated with increased risk of bleeding postoperatively.

Results

TG diminished significantly (p < 0.01) after heparinization in the presence and absence of platelets (37% and 50%) compared to baseline. After the start of CPB, TG elevated and persisted till the end of surgery but remained lower than preoperatively. Activated clotting time increased after heparinization and after the start of bypass compared to baseline (400% and 500%). Anti-FXa activity reduced on the start of CPB compared to the level after heparinization, to almost the baseline value following protamine reversal of heparin. The plasma levels of total and free TFPI elevated 9 and 14 fold during bypass and remained after protamine administration higher than preoperatively. Plasma D-dimer levels reduced (p < 0.01) when bypass started. However, a marked elevation was observed in the following time points. TG in platelet-rich plasma measured after heparinization and after the start of CPB associated (p < 0.05) with postoperative blood loss.

Conclusions

TG can be determined during CPB despite the high heparinization level, it reflects the haemostatic capacity better than clotting-based assays and might better predict bleeding when performed intraoperatively.     

Comparison of drug administration logistics between prothrombin complex concentrates and plasma in the emergency department

Background

Prothrombin complex concentrate (PCC) is used as an alternative to fresh frozen plasma (FFP) for emergency bleeding. The primary objective of this study was to compare the time from order to start of administration between 3-factor PCC (PCC3), 4-factor (PCC4), and FFP in the emergency department (ED). The secondary objective was to evaluate the effect of an ED pharmacist on time to administration of PCCs.

Effect of 24-hour whole-blood storageon plasma clotting factors

BACKGROUND: The current requirements for the preparation of fresh-frozen plasma within 8 hours of whole-blood collection were designed to maintain clotting factor activities. These requirements, however, limit the production of fresh-frozen plasma in a large blood center. There are few data on the effect of the extension of CPD whole-blood storage to 24 hours on clotting factor activity. STUDY DESIGN AND METHODS: A 500-mL unit of whole blood was collected from 10 volunteer donors. At 1 hour after collection, a plasma sample was separated by centrifugation, and each unit was equally divided into 2 half-units, with 1 half-unit stored at 4 degrees C (range, 1-6 degrees C) and 1 half-unit stored at 22 degrees C (range, 20-24 degrees C) for 8 hours after collection. Each half-unit was then placed at 4 degrees C for further storage for 16 hours. At 8 and 24 hours after collection, plasma samples were separated from each half-unit. All plasma samples were frozen at -18 degrees C. Factors V, VII, VIII, and X; fibrinogen; antithrombin III; protein C; and protein S were measured. RESULTS: No significant changes were noted in factors V, VII, and X; fibrinogen; antithrombin III; protein C; and protein S over the 24-hour storage period. Factor VIII in both half-units was significantly reduced, by 13 percent, from the baseline sample as compared to the level in the 8-hour storage sample (p<0.05). Factor VIII was further reduced by 15 to 20 percent after the 24-hour storage period (p<0.05). CONCLUSION: The coagulation factor activity for all factors measured, with the exception of factor VIII, showed no significant change over the 24-hour storage period. Factor VIII was significantly decreased by 13 percent in 8-hour storage and by an additional 15 to 20 percent in 24-hour storage. For clinical situations not requiring the replacement of factor VIII only, 24-hour frozen plasma has properties comparable to those of fresh-frozen plasma.     

Immune response to autologous transfusion in healthy volunteers: WB versus packed RBCs and FFP

BACKGROUND: Storage of blood as packed RBCs and FFP is standard practice in allogeneic transfusion. Separation into components has been proposed for autologous transfusion, as well, but beneficial effects have not yet been shown. STUDY DESIGN AND METHODS: Twenty-four healthy male volunteers were randomly assigned to receive 1 unit of either autologous RBCs and FFP (RCP group) or WB (WB group) after 49 or 35 days of storage, respectively. The immune response was analyzed by ELISA for IL-6, C3a, terminal complement complex SC5b-9, TNF-alpha, and neopterin. Differential WBC counts and the phagocytosis of neutrophils and monocytes were measured by flow cytometry. RESULTS: Cell counts of monocytes (0.85 x 10(3) ng/microL) [corrected] and neutrophils (6.9 x 10(3) ng/microL) [corrected] increased 30 minutes after WB transfusion and then returned to close to the baseline values seen in the RCP group (0.47 and 2.9 x 10(3) ng/microL [corrected], respectively) throughout the monitored period (p<0.05). C3a (169 vs. 116 ng/microL) [corrected] and IL-6 (29 vs. 6 pg/mL) reached higher plasma concentrations in the WB group (n = 11) than in the RCP group (n = 10). Phagocytosis of opsonized Escherichia coli was increased in neutrophils and monocytes and lasted up to 7 days after the transfusion of whole blood. CONCLUSION: Autologous WB induces a modest immunomodulation, but this effect is not observed upon transfusion of autologous blood components.     

我院输注新鲜冷冻血浆的合理性及有效性分析

目的探讨FFP在临床中应用的效果及临床科学、合理应用FFP的情况。方法收集2007年1月。2008年4月我院输注新鲜冷冻血浆（FFP）共200例（516次）的资料,分析临床医生输注FFP的目的;输注FFP的516例中有256例在输注前以及输注后8h内均检查了PT、APTT,根据现代FFP输注适应证标准,将256例分为非控制组56例和控制组200例,比较输注前及输注后8h内的Pr、APTT的检查结果并进行统计学分析。结果200例中临床医生输注FFP合理使用119例（59．5％）,输注血浆1027U（72．4％）,不合理使用81例（40．5％）,输注血浆391U（27．6％）;非控制组在输注FFP后的PT、APTT的值较输注前有缩短,但差异无统计学意义（P〉0．05）;控制组在输注FFP后PT、APTT的值较输注前有明显缩短,差异有统计学意义（P〈0．05）。结论根据现代FFP输注适应证标准,合理使用FFP能有效纠正凝血因子缺乏所致的出血;科学、合理、有效使用新鲜冷冻血浆的意识仍待加强。     

Fresh-frozen plasma and platelet transfusions are associated with development of acute lung injury in critically ill medical patients

BACKGROUND: Transfusion has long been identified as a risk factor for acute lung injury (ALI)/ARDS. No study has formally evaluated the transfusion of specific blood products as a risk factor for ALI/ARDS in critically ill medical patients. METHOD: In this single-center retrospective cohort study, 841 consecutive critically ill patients were studied for the development of ALI/ARDS. Patients who received blood product transfusions were compared with those who did not, in univariate and multivariate propensity analyses. RESULTS: Two hundred ninety-eight patients (35%) received blood transfusions. Transfused patients were older (mean [+/- SD] age, 67 +/- 17 years vs 62 +/- 19 years; p < 0.001) and had higher acute physiologic and chronic health evaluation (APACHE) III scores (74 +/- 32 vs 58 +/- 23; p < 0.001) than those who had not received transfusions. ALI/ARDS developed more commonly (25% vs 18%; p = 0.025) in patients exposed to transfusion. Seventeen patients received massive RBC transfusions (ie, > 10 U of blood transfused within 24 h), of whom 13 also received fresh-frozen plasma (FFP) and 11 received platelet transfusions. When adjusted for the probability of transfusion and other ALI/ARDS risk factors, any transfusion was associated with the development of ALI/ARDS (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.24 to 3.75). Among those patients receiving individual blood products, ALI/ARDS was more likely to develop in patients who received FFP transfusions (OR, 2.48; 95% CI, 1.29 to 4.74) and platelet transfusions (OR, 3.89; 95% CI, 1.36 to 11.52) than in those who received only RBC transfusions (OR, 1.39; 95% CI, 0.79 to 2.43). CONCLUSION: Transfusion is associated with an increased risk of the development of ALI/ARDS in critically ill medical patients. The risk is higher with transfusions of plasma-rich blood products, FFP, and platelets, than with RBCs.     

Use of plasma: Clinical indications and types of plasma components in Sweden

The use of plasma in Sweden is relatively high compared to other countries in the European Union. An analysis of all transfusion recipients in Orebro county during the whole year 2000 was performed. There were 3159 transfusion recipients of whom 96% had a registered diagnosis and 50% had undergone a "true" operation. Seven hundred and eleven patients (23%) had received plasma. Significantly more operated than nonoperated and more men than women received plasma. The typical plasma recipient was a man undergoing cardiovascular surgery. In Sweden there are two main types of plasma components: fresh frozen (FFP) and nonfrozen liquid plasma stored for up to 14 days, both considered to be clinically equal for most indications. The quality of these components as well as stored thawed FFP has been studied. The major storage effect was cold-induced contact activation and thereby consumption of C1 esterase inhibitor (C1INH) by day 14 in 22%. The citrate content in plasma sustained the overall coagulation function over 14 days. Other studies have shown that the levels of FV and ADAMTS 13 after 14 days remain at 70% or more compared to those for FFP. Since it is immediately available, liquid, nonfrozen or thawed, plasma is of great value in emergencies. Quality criteria for plasma components need to be assessed against evidence based indications and published in guidelines.     

Use of pharmacokinetic modelling to individualize FFP dosing in factor V deficiency

Therapy with fresh frozen plasma (FFP) confers serious risks, such as contraction of blood‐borne viruses, allergic reaction, volume overload and development of alloantibodies. The aim of this study was to apply principles of pharmacokinetic (PK) modelling to individual factor content of FFP to optimize individualized dosing, while minimizing potential risks of therapy. We used PK modelling to successfully target individual factor replacement in an 8‐month‐old patient receiving FFP for treatment of a severe congenital factor V (FV) deficiency. The model fit for the FV activity vs. time data was excellent (r = 0.98) and the model accurately predicted FV activity during the intraoperative and postoperative period. Accurate PK modelling of individual factor activity in FFP has the potential to provide better targeted therapy, enabling clinicians to more precisely dose patients requiring coagulation products, while avoiding wasteful and expensive product overtreatment, minimizing potentially life‐threatening complications due to undertreatment and limiting harmful product‐associated risks.