ECG guidance allows for more accurate CVC placement, and should be considered to increase patient safety and reduce costs associated with repositioning procedures.
We review contemporary coagulation management for patients undergoing liver transplantation. A better understanding of the complex physiologic changes that occur in patients with end-stage liver disease has resulted in significant advances in anesthetic and coagulation management. A group of internationally recognized experts have critically evaluated current approaches for coagulopathy detection and management. Strategies for blood component and factor replacement have been evaluated and recommended therapies proposed. Pharmacologic treatment and prevention of coagulopathy, management of patients receiving antiplatelet medications, and the role of transesophageal echocardiography for early detection and management of thromboses are presented.
After a hiatus of several decades, the concept of cold whole blood (WB) is being reintroduced into acute clinical trauma care in the United States. Initial implementation experience and data grew from military medical applications, followed by more recent development and data acquisition in civilian institutions. Anesthesiologists, especially those who work in acute trauma facilities, are likely to be presented with patients either receiving WB from the emergency department or may have WB as a therapeutic option in massive transfusion situations. In this focused review, we briefly discuss the historical concept of WB and describe the characteristics of WB, including storage, blood group compatibility, and theoretical hemolytic risks. We summarize relevant recent retrospective military and preliminary civilian efficacy as well as safety data related to WB transfusion, and describe our experience with the initial implementation of WB transfusion at our level 1 trauma hospital. Suggestions and collective published experience from other centers as well as ours may be useful to those investigating such a program. The role of WB as a significant therapeutic option in civilian trauma awaits further prospective validation.
Background. Intraoperative fluid management may affect the outcome after kidney transplantation. However, the amount and type of fluid administered, and monitoring techniques vary greatly between institutions and there are limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients. Methods. Members of the American Society of Anesthesiologists (ASA) committee on transplantation reviewed the current literature on the amount and type of fluids (albumin, starches, 0.9% saline, and balanced crystalloid solutions) administered and the different monitors used to assess fluid status, resulting in this consensus statement with recommendations based on the best available evidence. Results. Review of the current literature suggests that starch solutions are associated with increased risk of renal injury in randomized trials and should be avoided in kidney donors and recipients. There is no evidence supporting the routine use of albumin solutions in kidney transplants. Balanced crystalloid solutions such as Lactated Ringer are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. Central venous pressure is only weakly supported as a tool to assess fluid status. Conclusions. These recommendations may be useful to anesthesiologists making fluid management decisions during kidney transplantation and facilitate future research on this topic.
Pretreatment with E or Es appears to affect the onset time of rocuronium by altering CO as measured with the NICO (Non-Invasive Cardiac Output) monitor (Novametrix Medical Systems Inc., Willingford, CO).
Background and Purpose
Intracerebral hemorrhage (ICH) has high morbidity and hematoma enlargement (HE) causes worse outcome. Thrombelastography (TEG™) measures the dynamics of clot formation and dissolution, and might be useful for assessing bleeding risk. We used TEG™ to detect changes in clotting in patients with and without HE after ICH.
Methods
This prospective study included 64 patients with spontaneous ICH admitted from 2009 to 2013. TEG™ was performed within 6 hours of symptom onset and after 36 hours. Brain imaging was obtained at baseline and 36 ± 12 hours, and HE defined as total volume increase > 6cc or >33%. TEG™ was also obtained from 57 controls.
Results
Compared to controls, ICH patients demonstrated faster and stronger clot formation; shorter R and delta (p<0.0001) at baseline; and higher MA and G (p < 0.0001) at 36 hours. 11 patients had HE. After controlling for potential confounders, baseline K and delta were longer in HE + compared to HE − patients, indicating that HE+ patients had slower clot formation (p<0.05). TEG™ was not different between HE + and HE − patients at 36 hours.
Conclusions
TEG™ may detect important coagulation changes in patients with ICH. Clotting may be faster and stronger in immediate response to ICH and a less robust response may be associated with HE. These findings deserve further investigation.
Background
Thromboelastography (TEG) measures the dynamics of coagulation. There are limited data about TEG in acute ischemic stroke other than a single study from 1974 suggesting that acute ischemic stroke patients are hypercoagulable. There have been no studies of TEG in the thrombolytic era despite its potential usefulness as a measure of clot lysis. This study was designed to provide initial TEG data in stroke patients before and after tissue plasminogen activator (tPA) therapy, and to provide the necessary preliminary data for further study of TEG’s ability to identify clot subtype and predict response to tPA therapy.
Methods
All acute ischemic stroke patients presenting between 11/2009 and 2/2011 eligible for tPA therapy were screened and 56 enrolled. Blood was drawn before (52 patients) and 10 minutes after tPA bolus (30 patients). Demographics, vitals, labs, 24hr National Institutes of Health Stroke Scale (NIHSS) and computed tomography (CT) scan results were collected. Patients were compared to normal controls.
Results
Acute ischemic stroke patients had shorter R (4.8±1.5 vs 6.0 ±1.7 min, p =0.0004), greater a-Angle (65.0±7.6 vs 61.5 ± 5.9°, p =0.01), and shorter K (1.7 ±0.7 vs 2.1 ±0.7 min, p =0.002) indicating faster clotting. Additionally, a subset formed clots with stronger platelet-fibrin matrices. Treatment with tPA resulted in reduction in all indices of clot strength (LY30=0(0–0.4) vs 94.4 (15.2–95.3) p<0.0001), however there was considerable variability in response.
Conclusions
TEG demonstrates that many acute ischemic stroke patients are hypercoaguable. TEG values reflect variable clot subtype and response to tPA. Further study based on these data will determine if TEG is useful for measuring the dynamic aspects of clot formation and monitoring lytic therapy.
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