Should warm fresh whole blood be the first choice in acute massive hemorrhage in emergency conditions?

Early management of rapid massive hemorrhage requires early administration of blood products and rapid surgical control of bleeding. Professionals in peripheral hospitals with limited resources often work under conditions similar to those in the military. Described in the present report are 3 cases in which warm fresh whole blood (WFWB) was used in patients with massive bleeding who presented to a peripheral hospital that had no blood products suitable for emergency conditions. Described first is the case of a 16-year-old female patient who underwent emergency cesarean section. The patient had massive bleeding from the uterus due to atony. Her hemoglobin (Hb) dropped to 3.5 g/dL. Six units of WFWB were transfused during surgery. Hemodynamic parameters and complete blood count (CBC) stabilized. She was transferred from the intensive care unit (ICU) to obstetrics on day 2 and was discharged on day 7. Described second is the case of a 35-year-old female patient who also underwent emergency cesarean section, and for whom massive bleeding was due to uterine atony. Hb dropped to 2 g/dL and hematocrit (HCT) to 5.4%. Nine units of WFWB were transfused, after which hemodynamic and laboratory parameters stabilized. The patient was extubated the following day, transferred from the ICU to obstetrics on day 3, and was discharged on day 8. Described third is the case of a 36-year-old male patient with stab injuries and hemorrhagic shock who underwent emergency surgery. The patient had injuries to the right renal artery and kidney. Nine units of WFWB were transfused due to continued hemorrhage during surgery. Following surgical control of bleeding and transfusion, hemodynamic parameters improved. The patient was transferred from the ICU on day 5 and discharged on day 10. WFWB transfusion nearly disappeared from civilian medicine after blood was separated into components, and whole blood is not usually available at blood banks. In massive transfusions, WFWB effectively replaces red blood cells (RBCs), platelets, plasma volume, and coagulation factors, while preventing hypothermia and dilutional coagulopathy. Blood components go through biochemical, biomechanical, and immunological changes during long storage, the duration of which affects both transfusion efficacy and associated risks. In the future, with the use of fast donor tests, fast ABO compatibility tests, platelet-sparing leukocyte filters, and developments in pathogen-decreasing technology, fresh whole blood (FWB) may be the first choice for massive transfusion. Future studies will reveal new procedures

Effects of Laparoscopic Ureterolithotomy and Simultaneous Trans-Trocar Semi-Rigid Ureteroscopy on Stone-Free Rate in the Treatment of Proximal Ureteral Stones

Objective This study presents the effects of the use of semi-rigid ureteroscopy simultaneously during laparoscopic ureterolithotomy on the stone-free rate and, the techniques used to perform laparoscopic ureterolithotomy less invasively. Materials and Methods Between November 2011 and July 2013, laparoscopic ureterolithotomy was performed in 19 patients with proximal ureteral stones. A history of failed shock wave lithotripsy (SWL) or semi-rigid ureteroscopy (sr-URS), presence of ureter stones ≥15 mm and/or impacted stones, or a socioeconomic status not allowing the patient to reach an advanced center for flexible ureteroscopy (f-URS) were identified as the surgical indications. Results Fourteen male (74%) and five female (26%) patients were enrolled in the study and the mean age was 36.4±15.11 (15-70) years. The stones were located on right side in five patients (26%) and left side in 14 patients (74%). The mean stone size was 16.2±3.55 mm (8-22). The mean operation time was 138.9±29.56 minutes (90-200). The mean urethral catheter and drain removal time was 31.2±24.28 (16-120) and 50.8±33.61 hours (18- 168), respectively. There was no postoperative complication in long-term period and stone-free rate was 100%. Conclusion Laparoscopic ureterolithotomy is a feasible alternative in a patient who had previously failed minimally invasive methods and/or with large impacted proximal ureteral stone. Furthermore, to use semi-rigid ureteroscopy during the laparoscopic procedure increases the stonefree rate and prevents the need for an additional procedure in case of concurrent presence of small kidney stones

Comparison of Sugammadex and Neostigmine in Terms of Time to Extubation in Pediatrics

Aim: Sugammadex is a cyclodextrin compound which provides complete recovery of residual neuromuscular blockade. In this study, we compared sugammadex and neostigmine in terms of time to achieve a train-of-four (TOF) ratio of 0.9 and extubation time (TE). Methods: Thirty-seven patients, without lung disease and neuromuscular disease undergoing lower urinary tract surgery and inguinal hernia, were included in the study. Noninvasive arterial pressure, heart rate, pulse oximetry, and TOF-watch SX values were monitored during the surgery and, these parameters were recorded. After the surgery was completed, the patients were randomized into two groups: patients received either group neostigmine (group N) 0.05 mcg/kg and group sugammadex (group S) 2 mg/kg at reappearance of TOF ratio T2. Time to recovery to the TOF ratio of 0.9 (T0.9) and TE were compared between sugammadex and neostigmine Results: TE was found to be statistically longer in group N (6.06±2.47 minute) than in group S (4.30±2.48 minute) (p<0.041). Conclusion: We observed that sugammadex was more rapidly and effectively reversed the neuromuscular blockade compared to neostigmine. There were no serious adverse effects and significant hemodynamic changes in any measurement time. However, there is a limited number of studies on the safety and side effects of sugammadex in pediatric patients and additional data are needed to establish the safety in clinical practice