Transfusion
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The decision to transfuse red blood cells in surgical patients should be based on multiple clinical variables, rather than on isolated hemoglobin (Hb) measurements alone. An important but often unrecognized clinical variable is the postoperative downward drift in Hb concentration (Hb drift), but the etiology, predictors, and time course of Hb drift are not well understood. ⋯ Postoperative Hb drift was greater after surgical procedures with greater intraoperative IV fluid and blood requirements. Recognition of Hb drift may be an important facet of perioperative patient blood management.
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Sterile washing of red blood cells (RBCs) and use of an additive solution permits longer postwash storage. The effect of irradiation during this extended storage time is unclear. ⋯ The extended expiry for washed and washed and irradiated RBCs met requirements for all indications except transfusion to IgA-deficient recipients.
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Fibrinogen plays a critical role in achieving and maintaining hemostasis and is fundamental to effective clot formation. There is increasing awareness of the important role of fibrinogen as a key target for the treatment and prevention of acquired bleeding. Fibrinogen is the first coagulation factor to fall to critically low levels (<1.0 g/L) during major hemorrhage (normal plasma fibrinogen levels range from 2.0 to 4.5 g/L), and current guidelines recommend maintaining the plasma fibrinogen level above 1.5 g/L. ⋯ Administration of fibrinogen concentrate, often guided by point-of-care viscoelastic testing to allow individualized dosing, has been successfully used as hemostatic therapy in a range of clinical settings, including cardiovascular surgery, postpartum hemorrhage, and trauma. Results show that fibrinogen concentrate is associated with a reduction or even total avoidance of allogeneic blood product transfusion. Fibrinogen concentrate represents an important option for the treatment of coagulopathic bleeding; further studies are needed to determine precise dosing strategies and thresholds for fibrinogen supplementation.
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Cryoprecipitate may be used to treat bleeding in cardiac surgery. Its effects on plasma fibrinogen and fibrin clotting in this setting are poorly defined. ⋯ Cryoprecipitate increased plasma fibrinogen levels and fibrin-based clotting in bleeding patients undergoing aortic surgery with DHCA. In vivo recovery of fibrinogen was considerably below 100% and fibrinogen content varied between cryoprecipitate units. Trials are needed to assess whether cryoprecipitate impacts clinical outcomes and to evaluate its safety.