Plasma-containing products are given during the pre-anhepatic stage of liver transplant surgery to correct abnormal thromboelastogram (TEG) values and prevent blood loss due to coagulation defects. However, evidence suggests that abnormal TEG results do not always predict bleeding. We questioned what effect using higher TEG values to initiate treatment would have on blood loss. A single transfusion protocol was used for all patients who underwent liver transplantation between 2007 and 2010. Thirty-eight patients received coagulation products when standard TEG cutoff values were exceeded, whereas another 39 patients received coagulation products when the TEG values were 35% greater than normal. The results of postoperative coagulation tests for total blood loss and the use of blood products were compared for the 2 groups. When the critical TEG values for transfusion were higher, significantly fewer units of fresh frozen plasma (5.58 6 6.49 versus 11.53 6 6.66 U) and pheresis platelets (1.84 6 1.33 versus 3.55 6 1.43 U) were used. There were no differences in blood loss or postoperative blood product use. In conclusion, the use of higher critical TEG values to initiate the transfusion of plasma-containing products is not associated with increased blood loss. Further testing is necessary to identify what TEG value predicts bleeding due to a deficit in coagulation factors. Liver Transpl 18:1254-1258, 2012. V C 2012 AASLD.Received October 10, 2011; accepted June 13, 2012.Blood transfusions in liver transplant recipients are associated with an increased risk of infection and lung injury.1 This leads to increases in morbidity and mortality.2 Other outcome studies have shown that intraoperative transfusions of plasma products significantly reduce 1-year survival 3-5 and increase morbidity in liver transplant recipients. 6Physicians have used the thromboelastogram (TEG) as a tool for identifying abnormal coagulation. TEG can discriminate between different phases of the coagulation system and is, therefore, useful for identifying clotting abnormalities and guiding the administration of blood products.In 2007, we reported using less frozen plasma in transplant patients when transfusions were guided by standard TEG cutoff values instead of the international normalized ratio (INR)/prothrombin time and platelet counts. 7 We concluded that TEG was a
Characteristic signs of malignant hyperthermia (MH) include unexplained tachycardia, increased end-tidal carbon dioxide (Etco₂) concentration, metabolic and respiratory acidosis, and an increase in body temperature above 38.8°C. We present the case of a patient with highly probable MH. In addition to sinus tachycardia and metabolic and respiratory acidosis, this patient also had a negative arterial to Etco₂ gradient and an increased requirement for minute ventilation to maintain a normal Etco₂ concentration, with signs of increased CO₂ production. Despite these signs of MH, the patient's rectal temperature monitoring equipment did not show an increase in temperature, although the temperature measured in the mouth was increased. This case illustrates the unreliability of measuring rectal temperature as a means of reflecting body temperature during MH and the usefulness of increased CO₂ production signs in helping to diagnose MH.
We present a case of post-operative iatrogenic quadriplegia, which occurred after subtotal parathyroidectomy. This patient was on long-term hemodialysis for 7 years. The need of prolonged neck extension for this procedure was probably the main risk factor for the spinal cord injury. Systemic hypotension which contributed to the injury in this case, should be anticipated and promptly treated to prevent further damage. Spinal deformities associated with end-stage renal disease may make such patients more susceptible. Since appropriate precautions against potential neurologic damage can be undertaken, we suggest that evaluating carefully for the pre-existing spinal stenosis before a procedure requiring prominent and prolonged hyper-extension of the neck, especially in long-term hemodialysis patients is of paramount importance.
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