Objective Thromboelastography (TEG) measures the dynamics of clot formation in whole blood and provides data that can guide specific blood component therapy. This study analyzed whether the implementation of TEG affected blood product utilization and overall hemostasis in infants (6 months and younger) undergoing open heart surgery. Methods TEG values measured include R (time to fibrin formation), angle (fibrinogen formation), and MA (platelet function). Blood product usage, TEG values, and operative parameters were collected during surgery on 112 consecutive infants (66 acyanotic) undergoing open heart surgery within the first 6 months of life. Controls consisted of chart data on 70 consecutive patients (57 acyanotic) undergoing the same surgical procedures before implementation of TEG (pre-TEG). Results Using TEG, the pattern of blood product utilization changed. Compared with the pre-TEG era, TEG era patients demonstrated a significant increase in fresh frozen plasma usage intraoperatively (4.74 vs. 1.83 mL/kg; P < 0.001) and reduced postoperative use of platelets (1.69 vs. 3.74 mL/kg; P = 0.006) and cryoprecipitate (0.89 vs. 1.95 mL/kg; P = 0.149). Chest tube drainage was significantly reduced at 1, 2, and 24 hours in the TEG group. TEG angle and MA measurements suggest that fibrinogen and platelets of cyanotic patients are more sensitive to hemodilution than the acyanotic patients. Conclusions TEG allows for proactive, goal-directed blood component therapy with improved postoperative hemostasis in infants undergoing cardiopulmonary bypass.
A 20-year-old woman with Gardner syndrome and intra-abdominal desmoid tumors presented with increasing abdominal pain. CT demonstrated a new area of central hypodensity in a presumed desmoid tumor, compressing the left ureter. Findings were suspicious for abscess or fistula to the ureter. Subsequent 99mTc-MAG3 renogram demonstrated persistent extraureteral radiotracer activity in the region of the tumor, confirming a desmoid tumor-ureteral fistula. Desmoid tumors are benign but locally aggressive fibrous neoplasms that can be sporadic or associated with familial adenomatous polyposis syndromes, specifically Gardner syndrome. Fistula formation to the ureter has been reported infrequently.
Renal transplant perfusion curves obtained using Tc-99m MAG3 differ from those with Tc-99m DTPA. The perfusion curve can be divided into a first phase (up to the first-pass peak) and a second phase (the curve after the initial peak). The second phase of the MAG3 perfusion curve is usually ascending in contrast to the descending Tc-99m DTPA curve. This ascending MAG3 curve reflects early tubular extraction of MAG3. However, the second phase of the MAG3 curve is sometimes flat or descending. We hypothesized that a flat or descending curve reflects poor early tubular extraction and therefore graft dysfunction. Ninety-two studies of 59' renal transplant patients were retrospectively reviewed. The second phase of the perfusion curve was visually classified as ascending, flat, or descending. 77.2% of studies had ascending curves, 16.3% flat curves, and 6.5% descending curves. A descending curve had a positive predictive value (PPV) of 100% for medical graft dysfunction, while a flat curve had a PPV of 93.3%. A nonascending second phase curve was specific (96.4%) but not sensitive (33.9%) for graft dysfunction. Patients with acute tubular necrosis were not significantly more likely to have a nonascending curve than those with acute rejection. There was no significant difference in creatinine level between patients with medical graft dysfunction and ascending vs. nonascending curves. A nonascending second phase Tc-99m MAG3 perfusion curve is predictive for graft dysfunction. An ascending curve is nonspecific and can be seen in both normally and poorly functioning grafts.
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