Anaesthesia
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Trauma-induced coagulopathy represents a life-threatening complication in severely injured patients. To avoid exsanguination, rapid surgical bleeding control coupled with immediate and aggressive haemostatic treatment is mandatory. In most trauma centres, coagulation therapy is established with transfusion of high volumes of fresh frozen plasma. ⋯ An alternative for rapid improvement of haemostatic capacity is purified coagulation factor concentrates. They contain a well-defined concentration of coagulation proteins, carry a low risk for transfusion-related lung injury and virus transmission, and are available for immediate use without the need for blood group matching. In some European trauma centres, treatment algorithms have been developed for the administration of coagulation factor concentrates based on visco-elastic test results.
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Red cell transfusion therapy is a common treatment modality in contemporary medical practice. Although blood collection and administration is safer and more efficient than ever before, red cells undergo multiple metabolic and structural changes during storage that may compromise their functionality and viability following transfusion. ⋯ In the current review, we begin with an in-depth overview of the pathophysiological mechanisms underlying red cell storage, with a focus on altered metabolism, oxidative stress and red cell membrane damage. We proceed to review the current state of evidence on the clinical relevance and consequences of the red cell storage lesion, while discussing the strengths and limitations of clinical studies.
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It is estimated that up to 1% of the general population has a congenital bleeding disorder. With this level of disease burden, it is more likely than not that any practising surgeon or anaesthetist will, at one time or another, have occasion to manage one such patient. Congenital haemophilia, both A and B, von Willebrand's disease, and inherited qualitative platelet defects, constitute the bulk of these disorders, with the rest distributed between much rarer conditions. ⋯ Of equal importance, at least in developed countries, has been the ease of access to highly purified, safe and effective haemostatic products. The key to successful surgical management of the patient with a bleeding disorder is a multidisciplinary approach involving not only surgeons, anaesthetists and haematologists, but also laboratory scientists, specialist physiotherapists and haemophilia nurses. With careful planning, most surgical and invasive procedures can be carried out safely in persons with haemophilia and other bleeding disorders.
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Understanding the complex immunological consequences of red cell transfusion is essential if we are to use this valuable resource wisely and safely. The decision to transfuse red cells should be made after serious considerations of the associated risks and benefits. ⋯ Red cell transfusions should be acknowledged as immunological exposures, with consequences weighed against expected benefits. This article reviews immunological consequences and the emerging evidence that may inform risk-benefit considerations in clinical practice.
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Peri-operative coagulation monitoring should begin with the assessment of individual bleeding risk using a standardised bleeding history before the surgical procedure. Laboratory testing should be performed if this history is abnormal or peri-operative bleeding is anticipated. ⋯ In bleeding patients, routine coagulation tests should be requested, but one should be aware of the major limitations that exist. Delay whilst waiting for these laboratory results, which, in turn, aggravates coagulopathy, bleeding, blood product requirements, length of surgery and overall morbidity and mortality.