BACKGROUND:Damage control resuscitation targets acute traumatic coagulopathy with the early administration of high-dose fresh frozen plasma (FFP). FFP is administered empirically and as a ratio with ...the number of packed red blood cells (PRBC). There is controversy over the optimal FFP:PRBC ratio with respect to outcomes, and their hemostatic effects have not been studied. We report preliminary findings on the effects of different FFP:PRBC ratios on coagulation.
METHODS:This is a prospective observational cohort study of trauma patients requiring >4 U of PRBCs. Blood was drawn before and after each 4-U PRBC interval for prothrombin time and analysis by rotational thromboelastometry. Interval change in coagulation parameters were compared with the FFP:PRBC ratio received during each interval.
RESULTS:Sixty 4-U PRBC intervals from 50 patients were available for analysis. All measures of coagulation deteriorated with low FFP:PRBC ratios (<1:2). Maximal hemostatic effect was observed in the 1:2 to 3:4 group12% decrease in prothrombin time (p = 0.006), 56% decrease in clotting time (p = 0.047), and 38% increase in maximum clot firmness (p = 0.024). Transfusion with ≥1:1 ratio did not confer any additional improvement. There was a marked variability in response to FFP, and hemostatic function deteriorated in some patients exposed to 1:1 ratios. The beneficial effects of plasma were confined to patients with coagulopathy.
CONCLUSIONS:Interim results from this prospective study suggest that FFP:PRBC ratios of ≥1:1 do not confer any additional advantage over ratios of 1:2 to 3:4. Hemostatic benefits of plasma therapy are limited to patients with coagulopathy.
Introduction: This paper provides the results of a year-long evaluation of a large-scale integrated care pilot in North West London. The pilot aimed to integrate care across primary, acute, ...community, mental health and social care for people with diabetes and those over 75 years through: care planning; multidisciplinary case reviews; information sharing; and project management support.
Methods: The evaluation team conducted qualitative studies of change at organisational, clinician, and patient levels (using interviews, focus groups and a survey); and quantitative analysis of change in service use and patient-level clinical outcomes (using patient-level data sets and a matched control study).
Results: The pilot had successfully engaged provider organisations, created a shared strategic vision and established governance structures. However, engagement of clinicians was variable and there was no evidence to date of significant reductions in emergency admissions. There was some evidence of changes in care processes.
Conclusion: Although the pilot has demonstrated the beginnings of large-scale change, it remains in the early stages and faces significant challenges as it seeks to become sustainable for the longer term. It is critical that NHS managers and clinicians have realistic expectations of what can be achieved in a relatively short period of time.
Good blood management emphasises the importance of utilising blood components as part of an overall treatment strategy that is focused on improving patient outcome. Acute haemorrhage and acute ...anaemia are common in surgical, obstetric and critical care patients. This chapter reviews the evidence to guide blood management strategies in patients with critical illness or who are undergoing major surgery with an emphasis on those that have been shown to improve clinical outcomes. It also specifically considers changes in the management of massive haemorrhage/blood transfusion that have occurred in recent years, as this represents a clinical situation where appropriate blood management is a key determinant of patient outcomes, including survival. In acute haemorrhage, the therapeutic priority is to achieve source control; during this period, the aim is to maintain adequate oxygen delivery to prevent tissue hypoxia and organ dysfunction using fluids, red cells and interventions to prevent or correct coagulopathy.
Good blood management is an important determinant of outcome in critically ill patients, trauma patients and those undergoing major surgery or treatment for postpartum or upper gastrointestinal (GI) ...haemorrhage. These patients have a high red cell requirement, a significant proportion of which is administered for the reversal of acute anaemia in nonbleeding patients. More liberal administration of red cells in acutely anaemic patients increases the risk of adverse events and randomized controlled trial (RCT) evidence indicates that restrictive transfusion thresholds of 7 g/dL are safe in patients without cardiovascular disease. Coagulopathy is common in these patients where it is associated with worse outcome. Existing laboratory and point of care tests that are used to direct the management of coagulopathy lack diagnostic or prognostic accuracy; treatment is often empiric, and these patients utilize a significant proportion of all non‐red‐cell components. The evidence base to support current practice is weak and this is an important and underresourced area of research. Critically ill patients and those undergoing major surgery are cared for in highly monitored and controlled environments and this facilitates the use of therapeutic adjuncts that can reduce bleeding and transfusion exposure. Systematic reviews demonstrate that intraoperative cell salvage is cost effective and improves outcomes when used in major surgery. In massive haemorrhage associated with trauma, better outcomes may be achieved by administration of higher ratios of fresh frozen plasma (FFP) and platelets to red cells. Recent evidence has also indicated a survival advantage with the use of tranexamic acid in major trauma.
An American in Paris Curry, Nicola
Dance spirit,
07/2007, Letnik:
11, Številka:
6
Magazine Article
It's still difficult adjusting to the raked stage, but it's liberating performing Balanchine's Symphonie because of the freedom of movement in the choreography. Kevin McKenzie ABT artistic director ...and Susan Jones ABT ballet mistress are very complimentary of all of the corps girls.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
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