Vox sanguinis
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Treatment of massive blood loss has experienced major changes during the recent decade. The transition towards pure component therapy has been the most significant issue, which has compelled the clinician to revise some of their basic strategies in treatment of massively bleeding patients. The importance of adequate volume resuscitation with crystalloids and colloids is still unrefutable, but the therapy of hemorrhagic derangements has changed. ⋯ Hypofibrinogenemia develops first followed by other coagulation factor deficits and later by thrombocytopenia. Therefore the use of fresh frozen plasma (FFP) is the primary intervention to treat abnormal bleeding encountered in the replacement of massive blood loss with RC. As the development of thrombocytopenia is a highly individual phenomenon, the transfusion of platelets should be guided by repeatedly determined platelet counts.
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Circulatory deficiencies and the effectiveness of transfusion and fluid therapy may be evaluated by invasive and noninvasive monitoring after high risk surgery, hemorrhage, trauma, and sepsis in the ED, OR, and ICU. Earlier recognition and therapy of circulatory problems in emergency and critically ill patients to achieve optimal goals empirically defined by the survivors' patterns is recommended to improve outcome. WB, Prbc, and colloids markedly and statistically significantly improved pressure, flow, and tissue perfusion and best achieved these goals. Noninvasive monitoring may be used in the ED and OR shortly after admission to identify circulatory deficiencies and to titrate therapy, or they may be used initially as the front-end of subsequent invasive monitoring.
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Although we still do not know enough about the influence of anaemia and transfusion on outcomes for the surgical patient, it is possible to develop a general consensus about many aspects of management. A quality programme to improve consistency of practice in these consensus areas is feasible. (Table 6) This should be linked with further randomised trials to evaluate the clinical effectiveness of alternative regimes.
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The occurrence of iatrogenic cases of Creutzfeldt-Jakob disease (CJD) and the isolation of infectivity in some laboratory transmission studies in transmissible spongiform encephalopathies raises the possibility that CJD might be accidentally transmissible through blood or blood products. Epidemiological evidence, although not conclusive, does not suggest that classical CJD is transmitted through this route. However, new variant CJD (nvCJD) might pose greater risks of accidental transmission of infection and mechanisms to reduce the theoretical risk are under consideration. The theoretical risks from CJD and nvCJD must be balanced against the established therapeutic benefits of blood and blood products.