PHYSIOLOGIC TRANSFUSION TRIGGERS AND MASSIVE TRANSFUSION

Blood transfusion is often a life saving intervention, but can also be harmful. Restrictive transfusion protocols have recently been developed with a post transfusion target haemoglobin level of 70–100 g/l. Whether haemoglobin level on its own is enough to guide our transfusion policy is an important issue. This review was aimed to look at other possible, so called physiological indicators of blood transfusion what clinicians can be used in addition to haemoglobin during their everyday practice. In the second part of the paper the problems of the management of massive bleeding are reviewed. In both cases, a complex approach is requiredtaking into consideration physiological changes in order to individualize treatment and hence avoid harm that can be caused by unnecessary transfusion of blood products

Procoagulatio, hypercoagulatio és fibrinolysis „shut down” kimutatása ClotPro® viszkoelasztikus tesztek segítségével COVID–19-betegekben [Procoagulation, hypercoagulation and fibrinolytic “shut down” detected with ClotPro® viscoelastic tests in COVID-19 patients]

Bevezetés: Nemzetközi tapasztalatok alapján a COVID–19-fertőzött, kórházban kezelt betegek több mint 30%-ában vénás, artériás és microvascularis thrombosis, disszeminált intravascularis véralvadási zavar, illetve thromboembolia alakul ki. Ennek laboratóriumi jellemzői a magas D-dimer- és fibrinogénszint, valamint a megnyúlt prothrombinidő és aktivált parciális thromboplastinidő. Módszer: Az esetbemutatások során intenzív osztályon kezelt, COVID–19-fertőzött betegek (n = 3) ClotPro® tromb- olasztométeres (EX-test, IN-test, FIB-test, RVV-test és TPA-test) eredményeit értékeltük a klinikai állapottal össze- függésben. Eredmények: A ClotPro®-paraméterek procoagulatiót, hypercoagulatiót, fibrinolysist vagy annak „shut down” meg- nyilvánulását jelezték, és összhangban voltak a hagyományos alvadási tesztekkel, illetve a kompenzált disszeminált intravascularis coagulopathia meghatározásával. Következtetés: Eredményeink magyarázatot adhatnak a vénás thromboemboliás szövődményekre, támogatják a terá- piás alvadásgátló kezelés és a thrombocytaaggregáció-gátlás fontosságát. A gyógyszer típusának, adagolási algoritmu- sának, optimális időtartamának meghatározásához intervenciós klinikai vizsgálatok szükségesek, ezek engedélyezte- tése folyamatban van

Early procalcitonin kinetics and appropriateness of empirical antimicrobial therapy in critically ill patients: a prospective observational study

PURPOSE: The purpose was to investigate the value of procalcitonin (PCT) kinetics in predicting the appropriateness of empirical antimicrobial treatment in critically ill patients. MATERIALS AND METHODS: This prospective observational study recruited patients in whom empirical antimicrobial therapy was started for suspected infection. Biochemical and physiological parameters were measured before initiating antimicrobials (t0), 8 hourly (t8, t16, t24), and then daily (day2-6). Patients were grouped post hoc into appropriate (A) and inappropriate (IA) groups. RESULTS: Of 209 patients, infection was confirmed in 67%. Procalcitonin kinetics were different between the IA (n = 33) and A groups (n = 108). In the IA group, PCT levels (median [interquartile range]) increased: t0= 2.8 (1.2-7.4), t16= 8.6 (4.8-22.1), t24= 14.5 (4.9-36.1), P< .05. In the A group, PCT peaked at t16 and started to decrease by t24: t0= 4.2 (1.9-12.8), t16= 6.99 (3.4-29.1), t24= 5.2 (2.0-16.7), P< .05. Receiver operating characteristic analysis revealed that a PCT elevation greater than or equal to 69% from t0 to t16 had an area under the curve for predicting inappropriate antimicrobial treatment of 0.73 (95% confidence interval, 0.63-0.83), P< .001; from t0 to t24, a greater than or equal to 74% increase had an area under the curve of 0.86 (0.77-0.94), P< .001. Hospital mortality was 37% in the A group and 61% in the IA group (P= .017). CONCLUSIONS: Early response of PCT in the first 24 hours of commencing empirical antimicrobials in critically ill patients may help the clinician to evaluate the appropriateness of therapy

Central venous oxygen saturation and carbon dioxide gap as resuscitation targets in a hemorrhagic shock

BACKGROUND: Fluid resuscitation is still a major challenge. We aimed to describe changes in central venous oxygen saturation (ScvO2 ) and venous-to-arterial carbon dioxide gap (dCO2 ) during an experimental stroke volume (SV) index (SVI)-guided hemorrhage and fluid resuscitation model in pigs. METHODS: Twelve anesthetized, mechanically ventilated pigs were bled till baseline SVI (Tbsl ) dropped by 50% (T0 ), thereafter fluid resuscitation was performed with balanced crystalloid in four steps until initial SVI was reached (T4 ). Statistical analysis was performed with Statistical Program for Social Sciences version 18.0; data are expressed as mean +/- standard deviation. RESULTS: After bleeding, ScvO2 dropped (Tbsl = 78 +/- 7 vs. T0 = 61 +/- 5% P < 0.05) and oxygen extraction ratio increased (Tbsl = 0.20 +/- 0.07 vs. T0 = 0.36 +/- 0.05, P < 0.05). By T4 the ScvO2 normalized, but on average it remained 5% lower than at Tbsl (T4 = 73 +/- 9% P < 0.05) and oxygen extraction also remained higher as compared with Tbsl (T4 = 0.24 +/- 0.09 P = 0.001). ScvO2 showed significant correlation with SVI (r = 0.564, P < 0.001). dCO2 increased during hypovolemia (Tbsl :5.3 +/- 2.0 vs. T0 :9.6 +/- 2.3 mmHg, P = 0.001), then returned to normal by T4 = 5.1 +/- 2.6 mmHg, and it also showed significant correlation with SVI (R = -0.591, P < 0.001) and oxygen extraction (R = 0.735, P < 0.001). CONCLUSIONS: In this SV-guided bleeding and fluid resuscitation model, both ScvO2 and dCO2 correlated well with changes in SV, but only the dCO2 returned to its baseline, normal value, while ScvO2 remained significantly lower than at baseline. These results suggest that dCO2 may be a good hemodynamic endpoint of resuscitation, while ScvO2 is not strictly a hemodynamic parameter, but rather an indicator of the balance between oxygen delivery and consumption

Goal-directed resuscitation aiming cardiac index masks residual hypovolemia: an animal experiment

The aim of this study was to compare stroke volume (SVI) to cardiac index (CI) guided resuscitation in a bleeding-resuscitation experiment. Twenty six pigs were randomized and bled in both groups till baseline SVI (Tbsl) dropped by 50% (T0), followed by resuscitation with crystalloid solution until initial SVI or CI was reached (T4). Similar amount of blood was shed but animals received significantly less fluid in the CI-group as in the SVI-group: median = 900 (interquartile range: 850–1780) versus 1965 (1584–2165) mL, p=0.02, respectively. In the SVI-group all variables returned to their baseline values, but in the CI-group animals remained underresuscitated as indicated by SVI, heart rate (HR) and stroke volume variation (SVV), and central venous oxygen saturation (ScvO2) at T4 as compared to Tbsl: SVI = 23.8 ± 5.9 versus 31.4 ± 4.7 mL, HR: 117 ± 35 versus 89 ± 11/min SVV: 17.4 ± 7.6 versus 11.5 ± 5.3%, and ScvO2: 64.1 ± 11.6 versus 79.2 ± 8.1%, p<0.05, respectively. Our results indicate that CI-based goal-directed resuscitation may result in residual hypovolaemia, as bleeding caused stress induced tachycardia “normalizes” CI, without restoring adequate SVI. As the SVI-guided approach normalized most hemodynamic variables, we recommend using SVI instead of CI as the primary goal of resuscitation during acute bleeding