Blood transfusion management in the severely bleeding military patient

Purpose of review Hemorrhage remains the primary cause of preventable death on the battlefield and in civilian trauma. Hemorrhage control is multifactorial and starts with point-of-injury care. Surgical hemorrhage control and time from injury to surgery is paramount; however, interventions in the prehospital environment and perioperative period affect outcomes. The purpose of this review is to understand concepts and strategies for successful management of the bleeding military patient. Understanding the life-threatening nature of coagulopathy of trauma and implementing strategies aimed at full spectrum hemorrhage management from point of injury to postoperative care will result in improved outcomes in patients with life-threatening bleeding. Recent findings Timely and appropriate therapies impact survival. Blood product resuscitation for life-threatening hemorrhage should either be with whole blood or a component therapy strategy that recapitulates the functionality of whole blood. The US military has transfused over 10 000 units of whole blood since the beginning of the wars in Iraq and Afghanistan. The well recognized therapeutic benefits of whole blood have pushed this therapy far forward into prehospital care in both US and international military forces. Multiple hemostatic adjuncts are available that are likely beneficial to the bleeding military patient; and other products and techniques are under active investigation. Summary Lessons learned in the treatment of combat casualties will likely continue to have positive impact and influence and the management of hemorrhage in the civilian trauma setting. Correspondence to Philip C. Spinella, MD, FCCM, Director, Pediatric Critical Care Translational Research Program, Professor, Department of Pediatrics, Washington University in St Louis School of Medicine, Campus Box 8116, One Children's Place, Northwest Tower 10th Floor, St Louis, MO 63110, USA. Tel: +1 314 286 0858; fax: +1 210 8963462; e-mail: spinella_p@kids.wustl.edu Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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The Effects of Leukocyte Filtration on Cell Salvaged Autologous Blood Transfusion on Lung Function and Lung Inflammatory and Oxidative Stress Reactions in Elderly Patients Undergoing Lumbar Spinal Surgery

Background: This study was designed to investigate the effects of leukocyte filtration of autologous salvaged blood on lung function, lung inflammatory reaction, and oxidative stress reaction in elderly patients undergoing lumbar spinal surgery. Materials and Methods: Sixty elderly patients undergoing lumbar spinal surgery were randomly divided into 2 groups: Leukocyte Filter group and Control group. Serum levels of inflammatory markers including white blood cell and polymorphonuclear count, neutrophil elastase, serum surfactant protein A, methane dicarboxylic aldehyde, superoxide dismutase, interleukin (IL)-6, IL-8, tumor necrosis factor-α, and respiratory function markers including dynamic respiratory system compliance, oxygenation index, and respiratory index were measured immediately before induction of anesthesia (T0), immediately before blood transfusion (T1), and 1 (T2), 6 (T3), and 12 hours (T4) after end of blood transfusion. Results: The Leukocyte Filter group had higher dynamic respiratory system compliance at T2, oxygenation index at T2 and T3, respiratory index and superoxide dismutase at T2, T3, and T4 than those in the Control group (P

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Protecting the Brain With Xenon Anesthesia for Neurosurgical Procedures

Xenon possesses some, but not all, of the clinical features of an ideal anesthetic agent. Besides well-known advantages of rapid awakening, stable hemodynamics and lack of biotransformation, preclinical data lead to the expectation of xenon's advantageous use for settings of acute ongoing brain injury; a single randomized clinical trial using an imaging biomarker for assessing brain injury corroborated xenon's preclinical efficacy in protecting the brain from further injury. In this review, we discuss the mechanisms and hence the putative applications of xenon for brain protection in neurosurgery. Although the expense of this rare monoatomic gas will likely prevent its widespread penetration into routine clinical neurosurgical practice, we draw attention to the theoretical benefits of xenon anesthesia over other anesthetic regimens for awake craniotomy and for neurosurgery in older, high-risk, and sicker patients. M.M. is a cofounder and Board Member of NeuroproteXeon, a spinout company formed by Imperial College, London on the basis of patents that were filed when he was employed at that institution. NeuroproteXeon's mission is to develop xenon for clinical use to prevent acute ongoing neurological injury. M.M. has an equity stake in NeuroproteXeon through (i) founder status, (ii) exercised stock options, and (iii) personal investment. M.M is neither an employee of NeuroproteXeon nor does he have an executive role in the company. A.R. declares no funding or conflict of interest to disclose. Address correspondence to: Mervyn Maze, MB, ChB, Department of Anesthesia and Perioperative Care University of California San Francisco, 1001 Potrero Avenue, P.O. Box 1363, San Francisco, CA 94143 (e-mail: mervyn.maze@ucsf.edu). Received June 2, 2017 Accepted December 31, 2017 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved

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Acid–base balance during muscular exercise: response to Dr. Böning and Dr. Maassen

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Continuing Professional Development in Maternal Health Care: Barriers to Applying New Knowledge and Skills in the Hospitals of Rwanda

Abstract

Objectives Training healthcare professionals in emergency maternal healthcare is a critical component of improving overall maternal health in developing countries like Rwanda. This paper explored the challenges that healthcare professionals who participated in a Continuing Professional Development (CPD) program on Advanced Life Support in Obstetrics® (ALSO) face in putting the learned knowledge and skills into practice in hospitals of Rwanda. Methods This study used a mixed methods approach to understand the challenges/barriers to applying new knowledge and skills in the hospitals of Rwanda. We conducted thirteen purposive in-depth interviews with ALSO® trainees (nurses, midwives and physicians) complemented with a cross-sectional survey on staff turnover in eight of the nine hospitals in the Eastern province of Rwanda. Results Our study found that trainees do not get enough opportunity to apply the new knowledge and skills in their hospitals and expand to health centers. In part because they are frequently rotating to different departments of the hospital and are not getting the opportunity to train their colleagues to share the learned knowledge and skills. The lack of refresher trainings/mentorship and the high personnel turnover were also reported as a barrier to applying new knowledge and skills. Reasons for staff turnover included pursuing further studies, a better opportunity (job/remuneration), low morale, and family related motives including joining a spouse or better schools for children. Conclusions for Practice Expanding and formalizing CPD training to all the healthcare professionals involved in providing maternal care services would improve the provision of emergency maternal healthcare in Rwanda.

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Structural and Socio-cultural Barriers to Prenatal Care in a US Marshallese Community

Abstract

Objectives Pacific Islanders are disproportionately burdened by poorer perinatal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care. The aim of this study is to examine Marshallese mothers' beliefs, perceptions, and experiences of prenatal care and to identify potential barriers. Methods Three focus groups were conducted with Marshallese mothers, who were 18 years or older, and living in Arkansas. Focus groups focused on mothers' beliefs, perceptions, and experiences of prenatal care. A thematic qualitative analysis was conducted to identify salient themes within the data. Results The results demonstrated that negotiating health insurance, transportation, and language barriers were all major structural barriers that constrain prenatal care. The social–cultural barriers that emerged included a lack of understanding of the importance of seeking early and consistent prenatal care, as well as how to navigate the healthcare process. The more complicated challenges that emerged were the feelings of shame and embarrassment due to the perception of their age or being unmarried during pregnancy not being acceptable in American culture. Furthermore, the participants described perceived discrimination from prenatal care providers. Lastly, the participants described fear as a barrier to seeking out prenatal care. Conclusions for Practice This study identified both structural and socio-cultural barriers that can be incorporated into suggestions for policy makers to aid in alleviating maternal health disparities among Pacific Islander women. Further research is needed to address the Marshallese mothers' perceived discrimination from maternal health care providers.

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Molecular and clinical studies in eight patients with Temple syndrome

Temple syndrome (TS14, #616222) is a rare imprinting disorder characterised by phenotypic features including pre- and postnatal growth retardation, muscular hypotonia and feeding difficulties in infancy, early puberty and short stature with small hands and feet and often truncal obesity. It is caused by maternal uniparental disomies, paternal deletions and primary imprinting defects that affect the chromosomal region 14q32 and lead to a disturbed expression of imprinted genes in this region.

Here we present detailed clinical data of eight patients with Temple syndrome, four with an imprinting defect, two with an imprinting defect in a mosaic state as well as one complete and one segmental maternal uniparental disomy of chromosome 14.

Temple syndrome is a rare imprinting disorder caused by genetic and epigenetic disturbances of the imprinted region on chromosome 14q32. Detailed clinical description of eight patients with Temple syndrome due to different molecular causes (imprinting defects, mosaic imprint defects, maternal uniparental disomy of chromosome 14) and first description of a segmental maternal uniparental disomy of chromosome14q32 causing Temple syndrome.

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