Digital ischemia complicating pneumococcal sepsis: reversal with sympathetic blockade.
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Adult↗
Biomedical subjects
E Pavlin
Publications and source records attributed to E Pavlin.
Difficult intubation in the parturient.
Difficult or failed tracheal intubation is an important cause of anaesthetic-related maternal morbidity and mortality. The incidence of failed intubation in parturients is estimated to be as frequent as 1 in 500; that of mortality is unknown, although some 10-13 pregnant women in England, Scotland and Wales die each year because of anaesthetic-related complications. To prevent such catastrophes, all necessary monitors and equipment should be available, including that needed to deal with a failed intubation. Assessment of the patient may lead to preoperative recognition of a difficult airway; altered positioning may be of help both in recognition and management. Furthermore, adequate assistance, correct use of cricoid pressure, and confirmation of tracheal intubation are fundamental to safe practice. Lastly, should the anaesthetist fail to intubate the patient's trachea, a management protocol is suggested.
Anesthesia, Obstetrical↗
Clotting factor levels and the risk of diffuse microvascular bleeding in the massively transfused patient.
Clotting factor activities and coagulation screening tests in 36 massively transfused patients were measured after every 12 units of blood and whenever diffuse microvascular bleeding (MVB) developed. Moderate deficiencies in clotting factors were common, but they were not associated with MVB. MVB was associated with severe abnormalities of coagulation, i.e. a fibrinogen level less than 0.5 g/l or clotting factor levels less than 20%. The quantitative relationship between the prothrombin (PT) and partial thromboplastin (PTT) times and underlying clotting factor levels was explored by multiple linear regression. Clotting factor levels accounted for only 65-85% of the variability in these tests. However, clotting factor activities less than 20% were reliably reflected by marked prolongations of the PT and PTT (values greater than 1.8 times control). Our data suggest that commonly used replacement formulas are not likely to prevent MVB, since consumption of platelets and/or clotting factors, rather than simple dilution, is a major cause of the deficiencies leading to MVB. Modified whole blood alone was sufficient replacement therapy for most patients. Guidelines for transfusion of supplemental components during massive transfusion are given.
Blood Coagulation Factors↗
Prophylactic platelet administration during massive transfusion. A prospective, randomized, double-blind clinical study.
Prior studies at Harborview Medical Center have suggested that dilutional thrombocytopenia is a major etiology of microvascular, nonmechanical bleeding (MVB). We undertook a prospective randomized double-blind clinical study to compare the prophylactic effects of 6 units of platelet concentrates (PLT) versus 2 units of fresh frozen plasma (FFP) administered with every 12 units of modified whole blood in patients undergoing massive transfusion (12 or more units in 12 hours). After exclusions, three of 17 patients who received PLT and three of 16 patients who received FFP developed MVB, an incidence no different from our previous findings. Regression lines of platelet counts during transfusion were no different between groups, and both groups had higher platelet counts than predicted from a standard washout equation. Only one patient had evidence of dilutional thrombocytopenia as a cause for MVB. Prophylactic platelet administration is not warranted as a routine measure to prevent MVB.
Adult↗
Ventilation and perfusion alterations following homologous blood transfusion.
A previous study in this laboratory examined the effect of micropore ultrafiltration of blood products on pulmonary gas exchange and subsequent pulmonary dysfunction--related morbidity and death. Morbidity and death from pulmonary failure was not affected; however, gas exchange was improved following ultrafiltration with 40 micrometers filters, as reflected by lower Bohr dead-space fractions. This difference might be explained by reduction of the microaggregate load seen in the pulmonary microvasculature. The purpose of this study was to examine in more detail these gas exchange alterations, paying particular attention to the correlation of changing Bohr dead-space ventilation detected with multiple inert gas analysis with direct determinations of microaggregate size and number. Fourteen patients with isolated cutaneous thermal injury scheduled for major early burn would excision were selected for study. Following transfusion with homologous blood products, the ventilation/perfusion ratio (Va/Q) distributions determined by inert gas analysis remained essentially unchanged except for subtle changes in both high VA/Q and dead-space compartments, resulting in significantly increased Bohr dead-space fractions (P less than 0.05). This combination of gas exchange alteration is consistent with vasoactive and occlusive changes in the pulmonary microvasculature following microaggregate infusion. The correlation of changing dead-space ventilation with the total microaggregate load was poor (r = 0.15) but was significant when compared with counts of microaggregates greater than 90 micrometers in diameter (r - 0.85). These findings suggest that gas exchange alterations following blood transfusion are primarily reflected by increased dead-space ventilation secondary to vasoconstriction and occlusion of the pulmonary microvasculature with microaggregates greater than 90 micrometers in diameter.
Adolescent↗
Effect of micropore filtration on pulmonary function after massive transfusion.
1. This study demonstrates a positive correlation between the number and size of infused microaggregates and the subsequent abnormality in pulmonary function as measured by oxygenation and dead space. 2. No such correlation between the severity of injury and the altered pulmonary function or transfusion volume was demonstrated. 3. We were unable to demonstrate an advantage to the use of a 40 mu micropore filter in preventing the adult respiratory distress syndrome (ARDS) or in improving pulmonary function in our patients. 4. One explanation for the failure to demonstrate such an advantage is the low efficiency of the filter used.
Adolescent↗