The utility of recombinant factor VIIa as a last resort in trauma

Abstract Introduction The use of recombinant factor VII (rFVIIa) as a last resort for the management of coagulopathy when there is severe metabolic acidosis during large bleedings in trauma might be deemed inappropriate. The objective of this study was to identify critical degrees of acidosis and associated factors at which rFVIIa might be considered of no utility. Methods All massively transfused (≥ 8 units of red blood cells within 12 hours) trauma patients from Jan 2000 to Nov 2006. Demographic, baseline physiologic and rFVIIa dosage data were collected. Rate of red blood cell transfusion in the first 6 hours of hospitalization (RBC/hr) was calculated and used as a surrogate for bleeding. Last resort use of rFVIIa was defined by a pH≤ 7.02 based on ROC analysis for survival. In-hospital mortality was analyzed in last resort and non-last resort groups. Univariate analysis was performed to assess for differences between groups and identify factors associates with no utility of rFVIIa. Results 71 patients who received rFVIIa were analyzed. The pH> 7.02 had 100% sensitivity for the identification of potential survivors. All 11 coagulopathic, severely acidotic (pH ≤ 7.02) patients with high rates of bleeding (4RBC/hr) died despite administration of rFVIIa. The financial cost of administering rFVIIa as a last resort to these 11 severely acidotic and coagulophatic cases was $75,162 (CA). Conclusions Our study found no utility of rFVIIa in treating severely acidotic, coagulopathic trauma patients with high rates of bleeding; and thus restrictions should be set on its usage in these circumstances

A case of herpes simplex 2 encephalitis with an unusual radiographic manifestation

Herpes Simplex Virus (HSV) continues to be an important pathogen inflicting encephalitis in adults and children globally that entails high morbidity and mortality. Prompt diagnosis and treatment are the keys to minimize potential sequelae of the disease. Although HSV encephalitis-1(HSVE-1) is well recognized for its radiographic manifestation of temporal lobe involvement owing to its pathogenesis, radiographic features of HSVE-2 are less uniform. Lumbar puncture with HSV PCR testing is the gold standard for diagnosis. However, when lumbar puncture is not immediately obtainable, consideration of HSVE should be entertained in compatible clinical setting even in the absence of characteristic radiographic finding. We report a case of type 2 HSVE with atypical radiographic manifestation involving bilateral basal ganglia

The utility of recombinant factor VIIa as a last resort in trauma

Abstract Introduction The use of recombinant factor VII (rFVIIa) as a last resort for the management of coagulopathy when there is severe metabolic acidosis during large bleedings in trauma might be deemed inappropriate. The objective of this study was to identify critical degrees of acidosis and associated factors at which rFVIIa might be considered of no utility. Methods All massively transfused (≥ 8 units of red blood cells within 12 hours) trauma patients from Jan 2000 to Nov 2006. Demographic, baseline physiologic and rFVIIa dosage data were collected. Rate of red blood cell transfusion in the first 6 hours of hospitalization (RBC/hr) was calculated and used as a surrogate for bleeding. Last resort use of rFVIIa was defined by a pH≤ 7.02 based on ROC analysis for survival. In-hospital mortality was analyzed in last resort and non-last resort groups. Univariate analysis was performed to assess for differences between groups and identify factors associates with no utility of rFVIIa. Results 71 patients who received rFVIIa were analyzed. The pH> 7.02 had 100% sensitivity for the identification of potential survivors. All 11 coagulopathic, severely acidotic (pH ≤ 7.02) patients with high rates of bleeding (4RBC/hr) died despite administration of rFVIIa. The financial cost of administering rFVIIa as a last resort to these 11 severely acidotic and coagulophatic cases was $75,162 (CA). Conclusions Our study found no utility of rFVIIa in treating severely acidotic, coagulopathic trauma patients with high rates of bleeding; and thus restrictions should be set on its usage in these circumstances.</p

Management and outcomes of isolated renal artery aneurysms in the endovascular era

OBJECTIVE: Isolated renal artery aneurysms are rare, and controversy remains about indications for surgical repair. Little is known about the impact of endovascular therapy on selection of patients and outcomes of renal artery aneurysms. METHODS: We identified all patients undergoing open or endovascular repair of isolated renal artery aneurysms in the Nationwide Inpatient Sample from 1988 to 2011 for epidemiologic analysis. Elective cases were selected from the period 2000 to 2011 to create comparable cohorts for outcome comparison. We identified all patients with a primary diagnosis of renal artery aneurysms undergoing open surgery (reconstruction or nephrectomy) or endovascular repair (coil or stent). Patients with concomitant aortic aneurysms or dissections were excluded. We evaluated patient characteristics, management, and in-hospital outcomes for open and endovascular repair, and we examined changes in management and outcomes over time. RESULTS: We identified 6234 renal artery aneurysm repairs between 1988 and 2011. Total repairs increased after the introduction of endovascular repair (8.4 in 1988 to 13.8 in 2011 per 10 million U.S. population; P = .03). Endovascular repair increased from 0 in 1988 to 6.4 in 2011 per 10 million U.S. population (P < .0001). However, there was no concomitant decrease in open surgery (5.5 in 1988 to 7.4 in 2011 per 10 million U.S. population; P = .28). From 2000 to 2011, there were 1627 open and 1082 endovascular elective repairs. Patients undergoing endovascular repair were more likely to have a history of coronary artery disease (18% vs 11%; P < .001), prior myocardial infarction (5.2% vs 1.8%; P < .001), and renal failure (7.7% vs 3.3%; P < .001). In-hospital mortality was 1.8% for endovascular repair, 0.9% for open reconstruction (P = .037), and 5.4% for nephrectomy (P < .001 compared with all revascularization). Complication rates were 12.4% for open repair vs 10.5% for endovascular repair (P = .134), including more cardiac (2.2% vs 0.6%; P = .001) and peripheral vascular complications (0.6% vs 0.0%; P = .014) with open repair. Open repair had a longer length of stay (6.0 vs 4.6 days; P < .001). After adjustment for other predictors of mortality, including age (odds ratio [OR], 1.05 per decade; 95% confidence interval [CI], 1.0-1.1; P = .001), heart failure (OR, 7.0; 95% CI, 3.1-16.0; P < .001), and dysrhythmia (OR, 5.9; 95% CI, 2.0-16.8; P = .005), endovascular repair was still not protective (OR, 1.6; 95% CI, 0.8-3.2; P = .145). CONCLUSIONS: More renal artery aneurysms are being treated with the advent of endovascular techniques, without a reduction in operative mortality or a reduction in open surgery. Indications for repair of renal artery aneurysms should be re-evaluated