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Background: Decreased postpartum rotational thromboelastometric parameters of coagulation (ROTEM®) and fibrinogen levels have been associated with postpartum hemorrhage (PPH). However, the predictive power of prepartum ROTEM® parameters and fibrinogen levels (Fbgpre) for PPH remains unknown., Methods: This prospective observational pilot study included 217 healthy pregnant women. Maximum clot firmness (FIBTEM-MCF), fibrinogen levels and standard coagulation parameters were measured upon admission to the delivery room for labor and within 1 h after vaginal delivery. Blood loss was measured with a calibrated collecting drape during the third stage of labor. PPH was defined as blood loss ≥500 mL. Predictors for bleeding were identified via receiver operating characteristic analyses and bivariate and multivariate regression analyses., Results: Women with and without PPH did not differ in median FIBTEM-MCF [23 mm (25th percentile 20 mm, 75th percentile 26 mm) vs. 23 mm (19 mm, 26 mm), respectively; P=0.710] or mean Fbgpre (4.57±0.77 g/L vs. 4.45±0.86 g/L, respectively; P=0.431). Blood loss and prepartum coagulation parameters were not correlated (FIBTEM-MCF, rs=-0.055, P=0.431; Fbgpre, rs=-0.017, P=0.810). The areas under the curves (predictive power for PPH) for FIBTEM-MCF and Fbgpre and were 0.52 (0.41-0.64, P=0.699) and 0.53 [95% confidence interval (95% CI) 0.40-0.65, P=0.644], respectively. Neither FIBTEM-MCF nor Fbgpre was associated with PPH. However, primiparity [odds ratio (OR) 4.27, 95% CI 1.32-13.80, P=0.015) and urgent cesarean section (2.77, 1.00-7.67, P=0.050) were independent predictors of PPH., Conclusions: ROTEM® parameters, Fbgpre and postpartum blood loss were not associated, nor did these factors predict PPH. Sufficiently powered prospective studies are needed to confirm these results.

Background: Trauma-induced coagulopathy, one of the leading causes of trauma-related death, is detected in about one of four trauma patients upon hospital admission. The current European Management of Major Bleeding and Coagulopathy Following Trauma guidelines, published in 2013, recommend that tranexamic acid (TXA) be administered as early as possible to inhibit hyperfibrinolysis (grade of recommendation (GoR 1A)). Furthermore, it is suggested that protocols for the management of patients with bleeding or showing signs of bleeding include the administration of the first dose of TXA at the site of injury or during transportation to hospital (GoR 2C). There is no current data showing to what extent TXA is used in the pre-hospital settings in Germany., Objectives: This study aimed to collect data about the availability of TXA in the German emergency medical service (EMS). We tried to determine how many EMS stored and used TXA, under which circumstances the substance was used and whether any standard operating procedures (SOPs) were in use. The study also tried to determine what dosage recommendations exist., Materials and Methods: Between 1 July and 31 August 2015, a total of 326 German emergency medical directors (EMDs) were asked to take part in a survey, which involved answering an online questionnaire., Results: Altogether 163 EMD answered the questionnaire (response rate 50%). The results showed that 52.8% of EMDs stored TXA in their vehicles and 26% planned to do so in the future. The availability of TXA in the EMS has increased since 2010. Most EMDs stated that guidelines were the reason for this. SOPs existed in 17.4%. Dosage recommendations were defined by the EMDs in 76.7%. More than 80% of dosage recommendations followed the European guideline., Conclusion: The survey shows a widespread distribution of TXA in the German EMS, which has significantly increased between 2010 and 2015. However, nationwide distribution has not yet been established. This rise in distribution is interpreted as a reaction to national and European guidelines for the management of severe bleeding and trauma care. A remaining question is to determine which patients should be treated with TXA, as hyperfibrinolysis is not detectable at the site of injury.

Background: An increasing number of oral anticoagulants has been approved, including dabigatran etexilate (DE). DE is a direct thrombin inhibitor that requires no routine monitoring, but, if necessary (e.g. urgent surgery etc.), the diluted thrombin time measured with Hemoclot® has shown reliable results. So far, no point-of-care (PoC) assay is available to measure DE effects. The EcaTEM assay uses ecarin to initiate the coagulation cascade at the step of thrombin generation and measures the clotting time (CT) by thromboelastometry., Methods: This study investigated the correlation of the EcaTEM with standard laboratory assays in dabigatran-treated patients. Ten patients undergoing total hip or knee arthroplasty were included in the study. DE for thromboprophylaxis was started 4 h after surgery. Blood samples were taken before surgery as well as 2, 6 and 12 h after ingestion on the 3rd postoperative day. Dabigatran concentration (Hemoclot), activated partial thromboplastin time, thrombin time and CT EcaTEM were measured., Results: Only CT EcaTEM and Hemoclot showed a correlation > 0.75 for all measurements., Conclusion: CT EcaTEM appears a valid PoC method parameter to detect thrombin inhibition and thus the presence of dabigatran beside diluted thrombin time at different concentration levels. This may represent an opportunity to identify the presence of dabigatran, e.g., in emergency situations.

Background: Recent findings require an update of earlier recommendations on the perioperative management of non Vitamin K antagonist oral anticoagulants (NOAC)., Method: The present position paper summarises the outcomes of an expert panel discussion., Results and Conclusions: Based on the pharmacokinetic profile of rivaroxaban, a preoperative interruption of 24-72 hours is recommended depending on the patient's renal function, as well as individual and surgery-related bleeding risks. Similar NOAC-free intervals are recommended for patients with epidural catheters. Elective surgery should be delayed accordingly. A low molecular weight heparin (LMWH) "bridging" (in fact "switching") should be avoided because of an increased bleeding risk. Six to 8 hours after the intervention rivaroxaban can be re-initiated or, in case of more extensive interventions or an increased bleeding risk, after 24-72 hours; if necessary this interval could by bridged with LMWH, e. g. if the thromboembolic risk is considered high. In case of emergency surgery with a rivaroxaban pause of less than 9 hours, one should be prepared for a bleeding management including the use of prothrombin concentrate (PCC). Coagulation tests have no value for predicting perioperative bleeding, in contrast to a standardised bleeding history. As an overall estimate, the PT (Quick) can be determined with a suitable reagent. Currently, rivaroxaban-specific measurements of anti Xa levels are available at few specialised centres only. Moderate to severe haemorrhages can usually be managed by temporary interruption of rivaroxaban in conjunction with local and general haemostatic measures. Life-threatening bleeding events require a specific haemostasis management including the administration of PCC; these events are rare and usually have a favourable prognosis, except for intracranial haemorrhages.

Recent findings require an update of previous recommendations for the perioperative use of Direct Oral AntiCoagulants (DOACs). A break in preoperative treatment of 24-96 hours is recommended based on the pharmacokinetic profiles of DOACs and depends on individual patient characteristics, their renal and possibly liver function, and their surgery-related risk of bleeding. In cases of renal or hepatic insufficiency, whether to extend the preoperative interruption of IIa- and Xa-inhibitors is a clinical decision that must be reached on an individual patient basis. In cases of epidural or spinal anaesthesia, more conservative pausing-intervals are recommended due to the risk of persistent neurologic deficits (e.g., paraplegia) following the development of spinal subdural and epidural haematomas. Elective surgery should be postponed according to these recommendations. Preoperative "bridging" with LMWH (more precisely referred to as "switching") should be omitted due to a significantly increased risk of bleeding. In addition, the incidence of perioperative thromboembolic risks, such as DVT, PE, and stroke, are no different whether interruption or "switching" is undertaken. Postoperatively, the DOACs can be reinstituted within the first 24 hours. In cases of major surgery or if there is a higher risk of bleeding, resumption of DOACS should only begin after 24-72 hours. In patients with an elevated thromboembolic risk, transient postoperative LMWH administration can be recommended during this period.Interaction of DOACs with other drugs usually occurs during the absorption, transport and elimination of these drugs. Therefore, substance- specific restrictions and recommendations should be observed during these times. In everyday clinical practice, webbased, independent information portals on drug-interactions are very helpful in providing safe and rapid information about potential interactions when DOACs are used in combination with other drugs, especially during perioperative management.Non-adherence to medications is a worldwide problem that has dangerous and costly consequences. Present data suggest that persistence is the primary factor that supports adherence. Despite the adherence data presented in the DOACS approval studies (e.g., persistence in the treatment of acute venous thromboembolism has been reported to be between 94-99%), the first registries and meta-analyses provide sobering results regarding the incidence of persistence and the success rate of interventions designed to improve adherence with DOACs in cases of long-term usage., Competing Interests: Adj. Prof. Dr. J. Koscielny declares the following conflicts of interest: speaker honoraria from Aspen, Bayer Health Care Pharmaceuticals, Daiichi Sankyo, Boehringer Ingelheim, CSL Behring, Sanofi-Aventis, Pfizer, BMS, Mitsubishi Pharma, Ferring GmbH, Mylan Healthcare GmbH and Novo Nordisk. Adj. Prof. Dr. J. Koscielny is also a medical advisor for CSL Behring International, Bayer HealthCare Pharmaceuticals (national and international) and Novo Nordisk (national) for the last three years. Dr. C. Rosenthal received honoraria and/ or travel reimbursements over the last three years for lectures and consultancy work related to the topic of this article from Bayer AG, Boehringer Ingelheim, CSL Behring, Daiichi Sankyo, NovoNordisk, Pfizer GmbH and TEM International. Prof. Dr. C. von Heymann received honoraria and/or travel reimbursements over the last three years for lectures and consultancy work related to the topic of this article from Bayer AG, Shire, Boehringer Ingelheim, Pfizer GmbH, Bristol Myers Squibb, Daiichi Sankyo, CSL Behring, Leo Pharma, Mitsubishi Pharma, NovoNordisk, Ferring GmbH, Mylan Healthcare GmbH, Sanofi- Aventis and HICC GbR., (Schattauer GmbH.)

Background: Preoperative anemia and transfusion are associated with increased morbidity and mortality in cardiac surgery patients. It is unclear which of these factors plays the leading role in poor outcomes after cardiac surgery. The goal of this study was to analyze the influence of anemias of varying severity and intraoperative transfusion on long-term survival, and to characterize their interaction in cardiac surgery patients., Methods: This was an observational cohort study conducted at a German university hospital. All patients undergoing cardiac surgery between 2006 and 2011 were screened for eligibility; duration of follow-up was 3 years. A total of 4494 patients were suitable for analysis; data on long-term survival were available for 3131 of these patients. The main outcome measure was survival at the 3-year follow-up. Length of stay and in-hospital mortality were assessed as secondary outcomes., Results: Multivariate Cox regression analyses indicated that both the severity of preoperative anemia (mild anemia: hazard ratio [HR], 1.441; 95% confidence interval [CI], 1.201-1.728; severe anemia: HR, 1.805; 95% CI, 1.336-2.440) and intraoperative transfusion (HR, 1.340; 95% CI, 1.109-1.620) were associated with decreased long-term survival. Long-term survival was worse in anemic patients who received an intraoperative transfusion compared with those who did not receive an intraoperative transfusion., Conclusions: Both preoperative anemia and transfusion are by themselves and in combination associated with decreased long-term survival. When anemic patients require transfusion, our results provide evidence that the risk of death after cardiac surgery may depend to a considerable extent on the severity of preoperative anemia., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: A bleeding patient undergoing therapy with new oral anticoagulants is every clinician's nightmare as no specific reversal agent is available yet. This in vitro study investigated the effect of prothrombin complex concentrate (PCC), recombinant activated factor VII (rFVIIa) and activated prothrombin complex concentrate (aPCC) on supratherapeutic rivaroxaban concentrations using standard laboratory parameters (prothrombin time [PT], activated partial thromboplastin time [aPTT] and PT ratio) and thromboelastometry (clotting time [CT])., Materials and Methods: Blood samples from 10 healthy volunteers were collected and spiked with a supratherapeutic dose of rivaroxaban. Afterwards PCC, rFVIIa and aPCC were added in two doses. The laboratory parameters were measured and thromboelastometry was performed., Results: The addition of the reversal agents had the following statistically significant effects (all p<0.01): +25 IU/kg PCC: CT -15 s, aPTT +5 s; +50 IU/kg PCC: aPTT +11 s; +90 μg rFVIIa: CT -141 s; +25 IU/kg aPCC: CT -142 s, aPTT -9 s, PT ratio +14%, PT -10.5 s; +50 IU/kg aPCC: CT -118 s, aPTT -7 s, PT ratio +17%, PT -12.2 s., Discussion: rFVIIa and aPCC, but not PCC, appear to shorten coagulation times significantly in standard laboratory and thromboelastometry assays. These results need confirmation through evaluation of these agents in the clinical setting.

Worldwide, post-partum haemorrhage (PHH) remains one of the leading causes for maternal mortality. The German Society of Gynaecology and Obstetrics, the German Midwifes' Society, the German Society of Thrombosis and Haemostasis and the German Society of Anaesthesiology and Intensive Care updated the former guideline. The resulting recommendations are the results of a structured literature search and a formal consensus process and contain all aspects of PPH including diagnosis, causes, risk factors and therapy. Key aspect of the anaesthesiological and haemostatic therapies is the development of an interdisciplinary standard operating procedure containing medical options related to the bleeding's cause and severity as well as the surgical option. For suspected PPH, this guideline emphasizes clinical and laboratory-based diagnostics, as only those will enable an early identification of the bleeding's causes and the resulting causative therapy. Recommendations cover evidence-based application of uterotonics for atony as well as tranexamic acid, calcium, factor concentrates and blood products. Additionally, recommendations are given on the topics of cell salvage, controlled hypotension and restrictive transfusion triggers., (© Georg Thieme Verlag Stuttgart · New York.)

Objectives: Evacuation of shed blood from around the heart and lungs is a critical requirement for patients in early recovery after cardiac surgery. Incomplete evacuation of shed blood can result in retained blood, which may require subsequent reinterventions to facilitate recovery. The purpose of this study was to determine the incidence of retained blood requiring reintervention and examine the impact on outcomes., Methods: We performed a cross-sectional, observational study of all adult patients undergoing cardiac surgery between 2006 and 2013. Subjects who required an intervention to remove blood, blood clot, or bloodily fluid were attributed to the retained blood group. These patients were compared with those not presenting with any of the defined criteria for retained blood. Multivariate regression was performed to account for confounders., Results: Of 6909 adult patients who underwent cardiac surgery, 1316 (19%) presented with a retained blood-related condition. Retained blood was associated with increased in-hospital mortality (odds ratio [OR], 4.041; 95% confidence interval [CI], 2.589-6.351, P < .001) and a length of stay more than 13 days in the hospital (OR, 3.853; 95% CI, 2.882-5.206; P < .001) and 5 days in the intensive care unit (OR, 4.602; 95% CI, 3.449-6.183; P < .001). The OR for a time of ventilation greater than 23 hours was 3.596 (95% CI, 2.690-4.851; P < .001) and for incidence of renal replacement therapy was 4.449 (95% CI, 3.188-6.226; P < .001)., Conclusions: Postoperative retained blood is a common outcome and associated with higher in-hospital mortality, longer intensive care unit and hospital stay, and higher incidence of renal replacement therapy. Further research is needed to validate these results and explore interventions to reduce these complications., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

For secondary prevention of acute coronary syndrome, guidelines recommend dual antiplatelet therapy with acetylsalicylic acid and a P2Y12 receptor antagonist such as clopidogrel, prasugrel or ticagrelor for a period of 12 months. Premature discontinuation of dual antiplatelet therapy is associated with an increased risk of ischaemic events. However, antiplatelet therapy is also associated with an increased risk of bleeding that should not be under- or overestimated. To ensure an optimal care of patients receiving dual antiplatelet therapy after an acute coronary syndrome, an interdisciplinary group of experienced experts in the fields of cardiology, cardiac surgery, gastroenterology, anaesthesiology, intensive care and haemostaseology gathered bleeding-related information and developed recommendations relevant to daily clinical practice. These include the significance of bleeding events in the course of treatment, measures for bleeding prevention and the adequate care of patients with bleedings., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Cesarean section (CS) is associated with a moderate-high intensity of postoperative pain. We investigate whether continuous local anesthetic/opioid administration using patient controlled epidural anesthesia (PCEA) is superior in controlling pain after CS than epidural (ED) or intrathecal (IT) opioid bolus administration., Methods: One hundred ninety-nine women undergoing elective CS were randomized into 3 groups: PCEA: Combined spinal-epidural anesthesia (CSE) with a PCEA of ropivacaine 0.1% + sufentanil 0.5 μg/mL for 24 hours after CS. ED: CSE with an ED bolus of 3 mg morphine after CS. IT: spinal anesthesia with an IT bolus of 0.1 mg morphine before CS. Primary objectives were pain (VAS/Visual Analogue Scale 0-100) at 9 h, VAS at 1, 2, 6, 24 and 48 hours, side effects and additional analgesic requirements as secondary endpoints., Results: VAS (rest/mobilization) 10(0-23)/40(20-56) at 9 hours for IT was lower (P=0.11/P=0.003) than VAS 20(0-30)/50(30-60) for ED and 20(0-40)/50(30-70) for PCEA (P=0.005/P=0.01). VAS 10(0-29)/40(20-60) at 6 hours for IT was significantly lower than VAS 20(4-40)/50(30-70) for ED (P=0.02/P=0.02). During mobilization at 24/48 hours VAS 40(20-58)/30(20-40) between IT and PCEA with VAS 50(40-70)/40(20-63) differed significantly (P=0.04/P=0.001). With exception of pruritus, which was less in the PCEA group at 9 hours, side effects were similar in all groups. Ibuprofen consumption in the first 24 hours was significantly lower for IT and PCEA compared to ED., Conclusions: PCEA is less effective then IT and ED opioid bolus administration for post cesarean pain relief. IT provides better analgesia than ED or PCEA, as pointed out by lower ibuprofen consumption.

Aim: To evaluate the incidence of postpartum hemorrhage (PPH) and severe PPH via routine use of a pelvic drape to objectively measure blood loss after vaginal delivery in connection with PPH management., Methods: This prospective observational study was undertaken at the obstetrical department of the Charité University Hospital from December 2011 to May 2013 and evaluated an unselected cohort of planned vaginal deliveries (n=1019 live singletons at term). A calibrated collecting drape was used to meassure blood loss in the third stage of labor. PPH and severe PPH were defined as blood loss ≥500 mL and ≥1000 mL, respectively. Maternal hemoglobin content was evaluated at admission to delivery and at the first day after childbirth., Results: During the study period, 809 vaginal deliveries were analysed. Direct measurement revealed a median blood loss of 250 mL. The incidences of PPH and severe PPH were 15% and 3%, respectively. Mean maternal hemoglobin content at admission was 11.9±1.1 g/dL, with a mean decrease of 1.0±1.1 g/dL. Blood loss measured after vaginal delivery correlated significantly with maternal hemoglobin decrease., Conclusions: This study suggests that PPH incidence may be higher than indicated by population-based data. Underbuttocks drapes are simple, objective bedside tools to diagnose PPH. Blood loss should be quantified systematically if PPH is suspected.

Purpose of Review: This article emphasizes the differentiated management of direct oral anticoagulants (DOACs)-associated bleeding in trauma patients to generate a severity adjusted treatment protocol., Recent Findings: The management of DOAC-associated bleeding should take severity, mortality risk, and haemodynamic effects of the trauma-induced bleeding into account., Summary: The different pharmacological properties of DOACs are important for the management of trauma-induced bleeding. Comorbidities like renal impairment and liver dysfunction prolong their half-life. Patients with minor bleeding in stable clinical condition can be managed by a 'wait and see' approach. Moderate bleeding is suggested to be managed by a primarily conservative approach. In life-threatening bleeding, the administration of activated or nonactivated factor concentrates seems justified, together with supportive measures as part of an advanced management protocol. The administration of specific antidotes may be an alternative in the future. A monoclonal antibody to dabigatran (idarucizumab) has recently been approved by the Food and Drug Administration, whereas antidotes to Factor X activated inhibitors (andexanet and aripazine) are still under development. Sufficiently powered studies with clinical and safety outcome measures are still missing for all specific antidotes at this time.

Introduction: Central venous saturation (ScvO2) monitoring has been suggested to address the issue of adequate cardiocirculatory function in the context of cardiac surgery. The aim of this study was to determine the impact of low (L) (<60%), normal (N) (60%-80%), and high (H) (>80%) ScvO2 measured on intensive care unit (ICU) admission after cardiac surgery., Methods: We conducted a retrospective, cross-sectional, observational study at three ICUs of a university hospital department for anaesthesiology and intensive care. Electronic patient records of all adults who underwent cardiac surgery between 2006 and 2013 and available admission measurements of ScvO2 were examined. Patients were allocated to one of three groups according to first ScvO2 measurement after ICU admission: group L (<60%), group N (60%-80%), and group H (>80%). Primary end-points were in-hospital and 3-year follow-up survival., Results: Data from 4,447 patients were included in analysis. Low and high initial measurements of ScvO2 were associated with increased in-hospital mortality (L: 5.6%; N: 3.3%; H: 6.8%), 3-year follow-up mortality (L: 21.6%; N: 19.3%; H: 25.8%), incidence of post-operative haemodialysis (L: 11.5%; N: 7.8%; H: 15.3%), and prolonged hospital length of stay (L: 13 days, 9-22; N: 12 days, 9-19; H: 14 days, 9-21). After adjustment for possible confounding variables, an initial ScvO2 above 80% was associated with adjusted hazard ratios of 2.79 (95% confidence interval (CI) 1.565-4.964, P <0.001) for in-hospital survival and 1.31 (95% CI 1.033-1.672, P = 0.026) for 3-year follow-up survival., Conclusions: Patients with high ScvO2 were particularly affected by unfavourable outcomes. Advanced haemodynamic monitoring may help to identify patients with high ScvO2 who developed extraction dysfunction and to establish treatment algorithms to improve patient outcome in these patients.

Background: Patient blood management (PBM) can prevent preoperative anaemia, but little is known about practice in Europe., Objective: To assess the pre and postoperative prevalence and perioperative management of anaemia in patients undergoing elective orthopaedic surgery in Europe., Design: An observational study; data were collected from patient records via electronic case report forms., Setting: Seventeen centres in six European countries. Centres were stratified according to whether they had a PBM programme or not., Patients: One thousand five hundred and thirty-four patients undergoing major elective hip, knee or spine surgery [49.9% hip, 37.2% knee, 13.0% spine; age 64.0 years (range 18 to 80), 61.3% female]., Main Outcome Measures: Prevalence of preoperative (primary endpoint) and postoperative anaemia [haemoglobin (Hb) <13 g dl (male), Hb <12 g dl (female)], perioperative anaemia management, time to first blood transfusion and number of transfused units. Data are shown as mean (SD) or median (interquartile range)., Results: Anaemia prevalence increased from 14.1% preoperatively to 85.8% postoperatively. Mean Hb decrease was 1.9 (1.5) and 3.0 (1.3) g dl in preoperatively anaemic and nonanaemic patients, respectively (P < 0.001). In PBM (n = 7) vs. non-PBM centres, preoperative anaemia was less frequent (8.0 vs. 18.5%; P < 0.001) and iron status was assessed more frequently (ferritin 11.0 vs. 2.6%, transferrin saturation 11.0 vs. 0.1%; P < 0.001). Perioperative anaemia correction (mainly transfusion) was given to 34.3%. Intraoperatively, 14.8% of preoperatively anaemic and 2.8% of nonanaemic patients received transfusions [units per patient: 2.4 (1.5) and 2.2 (1.4), median time to first intraoperative transfusion: 130 (88, 158) vs. 179 (135, 256) min; P < 0.001]. Postoperative complications were more frequent in preoperatively anaemic vs. nonanaemic patients (36.9 vs. 22.2%; P = 0.009)., Conclusion: Most patients who underwent elective orthopaedic surgery had normal preoperative Hb levels but became anaemic after the procedure. Those who were anaemic prior to surgery had an increased intraoperative transfusion risk and postoperative complication rate. PBM measures such as iron status assessment and strategies to avoid transfusion are still underused in Europe.

Objective: Parameters such as central venous oxygen saturation (ScvO2) are used increasingly to monitor adequate hemodynamic treatment. However, it still remains challenging to identify patients with assumed adequate circulatory status quantified by ScvO2 who suffer from macro- and microcirculatory hypoperfusion. The authors hypothesized that central venous-arterial pCO2 difference (dCO2) could serve as an additional parameter to evaluate the adequacy of perfusion in cardiac surgery patients., Design: Retrospective data analysis of a prospective interventional study., Setting: University medical center., Participants: Patients undergoing surgery with cardiopulmonary bypass., Interventions: The dCO2 was measured postoperatively. The patients with an ScvO2≥70% were divided into 2 groups, the high-dCO2 group (≥8 mmHg) and the low-dCO2 group (<8 mmHg)., Measurements and Main Results: Sixty patients were included in this analysis. Twenty-five patients had ScvO2≥70%, 4 patients were assigned to the high-dCO2 group. Patients of the high-dCO2 group had significantly longer intensive care unit (ICU) stays (4 d; 1-29 v 1 d; 1-1; p = 0.02), significantly prolonged need for mechanical ventilation (41.5 h; 11-263.5; v 10 h; 7-11; p = 0.03), and higher cardiovascular complication rates in the ICU on postoperative days 3, 4, and 5 (p = 0.02). The mixed venous saturation (SvO2) after 1 hour in the ICU was significantly lower, lactate levels were significantly higher, and the plasma disappearance rate of indocyanine green was significantly lower after 1 hour in the ICU (14.6%/min; 11.6-19.8%/min v 23.6%/min; 22.5-27.3%/min; p = 0.02) in the high-dCO2 group. Cytokines increased significantly postoperatively in the high-dCO2 group., Conclusions: The authors described dCO2 as a routinely available tool to detect global and microcirculatory hypoperfusion in postoperative cardiac surgical patients. The authors showed that in patients with an ScvO2≥70%, a high dCO2 (≥8 mmHg) was associated with increased postoperative lactate levels and decreased splanchnic function. These findings were associated with a longer need for mechanical ventilation and longer ICU stay., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Volume substitution using colloids and crystalloids dose-dependently induces dilutional coagulopathy. For treatment, fibrinogen concentrate and fresh frozen plasma are options, though the effective dosage of either agent is unclear. The objective of this study was to evaluate, whether high-dose fibrinogen or recommended doses of fresh frozen plasma are equally effective in reversing profound dilutional coagulopathy in vitro., Methods: Blood samples of ten healthy volunteers were diluted by 60% with normal saline, balanced 4% gelatin, or balanced 6% hydroxyethyl starch 130/0.42, and supplemented with either 85mg/kg fibrinogen concentrate or 20mL/kg fresh frozen plasma. Conventional coagulation assays (prothrombin time, activated partial thromboplastin time, plasma fibrinogen, factors V and VIII), and activated rotational thromboelastometry (EXTEM: clotting time, clot formation time,, Fibtem: maximum clot firmness) were performed in all samples., Results: For saline and gelatin dilutions, plasma fibrinogen and thromboelastometry parameters normalized by fibrinogen concentrate, while conventional coagulation assays and factors V and VIII remained unaffectedly impaired. Fresh frozen plasma improved both conventional coagulation assays, coagulation factors, and thromboelastometry parameters in saline and gelatin dilutions. For hydroxyethyl starch dilutions, plasma fibrinogen increased by fresh frozen plasma, and even normalized by fibrinogen concentrate. Conventional coagulation assays and factors V and VIII improved by fresh frozen plasma only. Thromboelastometry parameters remained mainly unaffected impaired by both fibrinogen concentrate and fresh frozen plasma., Conclusion: High-dose fibrinogen concentrate and clinically recommended doses of fresh frozen plasma are equally effective and can partially restore viscoelastic coagulation assays in profound saline and gelatin dilutions, but only fresh frozen plasma improves conventional coagulation assays. Hydroxyethyl starch-induced disturbance of fibrin polymerization is neither restored by fibrinogen concentrate nor fresh frozen plasma.

Objectives: Perioperative bleeding is common among patients undergoing cardiac surgery; however, the definition of perioperative bleeding is variable and lacks standardization. We propose a universal definition for perioperative bleeding (UDPB) in adult cardiac surgery in an attempt to precisely describe and quantify bleeding and to facilitate future investigation into this difficult clinical problem., Methods: The multidisciplinary International Initiative on Haemostasis Management in Cardiac Surgery identified a common definition of perioperative bleeding as an unmet need. The functionality and usefulness of the UDPB for clinical research was then tested using a large single-center, nonselected, cardiac surgical database., Results: A multistaged definition for perioperative bleeding was created based on easily measured clinical end points, including total blood loss from chest tubes within 12 hours, allogeneic blood products transfused, surgical reexploration including cardiac tamponade, delayed sternal closure, and the need for salvage treatment. Depending on these components, bleeding is graded as insignificant, mild, moderate, severe, or massive. When applied to an established cardiac surgery dataset, the UDPB provided insight into the incidence and outcome of bleeding after cardiac surgery., Conclusions: The proposed UDPB in adult cardiac surgery provides a precise classification of bleeding that is useful in everyday practice as well as in clinical research. Once fully validated, the UDPB may be useful as an institutional quality measure and serve as an important end point in future cardiac surgical research., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Perioperative red blood cell transfusion is associated with adverse outcomes after cardiac operations. Although restrictive transfusion protocols have been developed, their safety and efficacy are not well demonstrated, and considerable variation in transfusion practice persists. We report our experience with a restrictive transfusion protocol., Methods: We analyzed the outcomes in 409 patients undergoing cardiac operations enrolled in a trial conducted at 30 centers worldwide. Blood products were administered on the basis of a transfusion algorithm applied across all centers, with a restrictive transfusion trigger of hemoglobin less than or equal to 6 g/dL. Transfusion was acceptable but not mandatory for hemoglobin 6 to 8 g/dL. For hemoglobin 8 to 10 g/dL, transfusion was acceptable only with evidence for end-organ ischemia., Results: The patient population was moderately complex, with 20.5% having combined procedures and 29.6% having nonelective operations. The mean EuroSCORE for the population was 4.3, which predicted a substantial incidence of morbidity and mortality. Actual outcomes were excellent, with observed mortality of 0.49% and rates of cerebrovascular accident, myocardial infarction, and acute renal failure 1.2%, 6.1%, and 0.98%, respectively. The frequency of red blood cell transfusion was 33.7%, which varied significantly by center. Most transfusions (71.9%) were administered for hemoglobin 6 to 8 g/dL; 21.4% were administered for hemoglobin 8 to 10 g/dL with evidence for end-organ ischemia; 65.0% of patients avoided allogeneic transfusion altogether., Conclusions: A restrictive transfusion protocol can be safely applied in the care of moderate-risk patients undergoing cardiac operations. This strategy has significant potential to reduce transfusion and resource utilization in these patients, standardize transfusion practices across institutions, and increase the safety of cardiac operations., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Hydroxyethyl starch (HES) is known to impair blood coagulation. The impact of calcium-containing, balanced carrier solutions of HES on coagulation is controversial. We investigated the effects of increasing degrees of haemodilution with modern 6%, electrolyte-balanced HES vs non-balanced HES on coagulation in vitro, and compared the balanced HES to a balanced crystalloid solution for an internal control., Materials and Methods: Blood samples from ten healthy volunteers were diluted in vitro by 20%, 40% and 60% with either calcium-containing balanced 130/0.42 HES, non-balanced 130/0.4 HES or balanced crystalloid. In all samples, blood counts, prothrombin time ratio, activated partial thromboplastin time, ionized calcium, factor VIII activity, von Willebrand factor antigen, von Willebrand factor collagen binding activity, and von Willebrand factor activity were determined, and activated rotational thromboelastometry (EXTEM and FIBTEM assays) was performed., Results: Haemodilution impaired coagulation in a dilution-dependent manner as determined by both conventional laboratory assays and thromboelastometry. Ionized calcium increased with balanced HES (p≤0.004), but decreased with non-balanced HES (p≤0.004). Prothrombin time ratio (p≤0.002) and factor VIII levels (p=0.001) were better preserved with balanced HES than with non-balanced HES in dilutions ≥40%. Thromboelastometry showed no differences between values in blood diluted with the balanced or non-balanced HES., Discussion: In vitro, a balanced calcium-containing carrier solution of 6% HES 130/0.42 preserved coagulation better than did non-balanced HES 130/0.4 as quantified by conventional coagulation assays, but not in activated thromboelastometry. One explanation could be the increased ionized calcium levels after dilution with calcium-containing carrier solutions.

The new oral anticoagulants directly inhibit either thrombin (Dabigatran, Pradaxa®,) or activated Factor X (rivaroxaban, Xarelto®, and apixaban, Eliquis®) and have been approved for thromboprophylaxis after hip and knee replacement surgery and stroke prevention in non-valvular atrial fibrillation. Moreover, rivaroxaban has been approved for the treatment of deep venous thrombosis, prevention of pulmonary embolism and anticoagulation after acute myocardial infarction. The direct FXa-inhibitor edoxaban (Lixiana®) expects approval for the prevention of stroke in atrial fibrillation in Germany in 2014. The half lives of all direct anticoagulants range between 8 and 17 hours. Dabigatran (Pradaxa®) and rivaroxaban (Xarelto®) are mainly excreted by the kidneys, apixaban (Eliquis®) by the liver (75%) and edoxaban (Lixiana®) by the kidneys (40%) and the faeces in 60%. Prior to surgery a shorter cessation is expected compared to the vitamin k antagonists phenprocoumon (Marcumar®, Falithrom®) and warfarin (Coumadin®). For acute bleedings caused by the direct thrombin inhibitor dabigatran (Pradaxa®) hemodialysis is recommended to eliminate the drug from the plasma. Due to the high protein binding the direkt FXa-inhibitors rivaroxaban (Xarelto®) and apixaban (Eliquis®) can not be hemodialysed. For edoxaban (Lixiana®) no data on elimination by renal replacement therapy are available. In case of life-threatening bleeding the replacement of a prothrombin complex preparation (PCC) containing the factors II, VII, IX and X and, second line, activated factor concentrates as recombinant factor VIIa or activated prothrombin complex preparations are recommended., (© Georg Thieme Verlag Stuttgart · New York.)

Objectives: Cardiac surgery with cardiopulmonary bypass frequently leads to excessive bleeding, obligating blood product transfusions. Because low factor XIII (FXIII) levels have been associated with bleeding after cardiac surgery, we investigated whether administering recombinant FXIII after cardiopulmonary bypass would reduce transfusions., Methods: In this double-blinded, placebo-controlled, multicenter trial, 409 cardiac surgical patients at moderate risk for transfusion were randomized to receive an intravenous dose of recombinant FXIII, 17.5 IU/kg (n = 143), 35 IU/kg (n = 138), or placebo (n = 128) after cardiopulmonary bypass. Transfusion guidelines were standardized. The primary efficacy outcome was avoidance of allogeneic blood products for 7 days postsurgery. Secondary outcomes included amount of blood products transfused and reoperation rate. Serious adverse events were measured for 7 weeks., Results: Study groups had comparable baseline characteristics and an approximately 40% decrease in FXIII levels after cardiopulmonary bypass. Thirty minutes postdose, FXIII levels were restored to higher than the lower 2.5th percentile of preoperative activity in 49% of the placebo group, and 85% and 95% of the 17.5- and 35-IU/kg recombinant FXIII groups, respectively (P < .05 for both treatments vs placebo). Transfusion avoidance rates were 64.8%, 64.3%, and 65.9% with placebo, 17.5 IU/kg, and 35 IU/kg recombinant FXIII (respective odds ratios against placebo, 1.05 [95% confidence interval, 0.61-1.80] and 0.99 [95% confidence interval, 0.57-1.72]). Groups had comparable adverse event rates., Conclusions: Replenishment of FXIII levels after cardiopulmonary bypass had no effect on transfusion avoidance, transfusion requirements, or reoperation in moderate-risk cardiac surgery patients (ClinicalTrials.gov identifier: NCT00914589)., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Transfusion of allogeneic blood is still common in orthopedic surgery. This analysis evaluates from the perspective of a German hospital the potential cost savings of Epoetin alfa (EPO) compared to predonated autologous blood transfusions or to a nobloodconservationstrategy (allogeneic blood transfusion strategy)during elective hip and knee replacement surgery., Methods: Individual patients (N = 50,000) were simulated based on data from controlled trials, the German DRG institute (InEK) and various publications and entered into a stochastic model (Monte-Carlo) of three treatment arms: EPO, preoperative autologous donation and nobloodconservationstrategy. All three strategies lead to a different risk for an allogeneic blood transfusion. The model focused on the costs and events of the three different procedures. The costs were obtained from clinical trial databases, the German DRG system, patient records and medical publications: transfusion (allogeneic red blood cells: €320/unit and autologous red blood cells: €250/unit), pneumonia treatment (€5,000), and length of stay (€300/day). Probabilistic sensitivity analyses were performed to determine which factors had an influence on the model's clinical and cost outcomes., Results: At acquisition costs of €200/40,000 IU EPO is cost saving compared to autologous blood donation, and cost-effective compared to a nobloodconservationstrategy. The results were most sensitive to the cost of EPO, blood units and hospital days., Conclusions: EPO might become an attractive blood conservation strategy for anemic patients at reasonable costs due to the reduction in allogeneic blood transfusions, in the modeled incidence of transfusion-associated pneumonia andthe prolongedlength of stay.

Background: With increasing numbers of implanted pacemakers and implantable cardioverter defibrillators (ICD) and a rising incidence of malignant tumors, there is a growing probability of radiation-mediated device dysfunction. The only guidelines for the management of patients with cardiac pacemakers in the case of radiation therapy were published in 1994 and have not been updated since then. Based on the current evidence and modern device technology, the present paper aims to develop contemporary and interdisciplinary safety recommendations for the minimization of patient risk., Methods and Results: A systematic literature research was carried out including the most relevant medical electronic databases. The search yielded 147 articles published between 1994 and 2012 of which 45 met the selection criteria and of these studies 34 presented primary data (9 in vitro and 25 in vivo studies). The impact of ionizing radiation varied significantly between implanted devices and ranged from no functional changes to complete loss of function. Important device dysfunctions included changes in sensing capability, altered pacing pulses or rate, changed or disabled tachyarrhythmia ICD therapies, early battery depletion and loss of telemetry. Modern pacemakers and ICDs are more sensitive to radiation than older models. Potentially life-threatening complications were observed after exposure of the pulse generator to comparatively low radiation doses (0.11 Gy)., Conclusions: Practical recommendations for patient management and safety are presented that can be readily adopted by any institution carrying out radiation therapy.

The increasing understanding of trauma-induced coagulopathy has led to an expansion of treatment strategies in the acute management of trauma patients. The aim of this manuscript is to give a summary of current recommendations for the treatment of trauma-induced coagulopathy based on current literature and valid guidelines. Thetrauma-induced coagulopathyis an independentacutemultifactorial diseasewith significantimpact on the mortalityof severelyinjured patients. Largely responsible for the occurrence and severity of trauma-induced coagulopathy seems to be tissue trauma and shock-induced hypoperfusion. Coagulopathy is amplified by accompanying factors such as hypothermia or dilution. Diagnosis and therapy of deranged coagulation should start as soon as possible. Routinely tested coagulation parameters are of limited use to confirm diagnosis. Therapy follows the concept of "damage control resuscitation". Infusion of large volumes should be avoided and a mean arterial pressure of 65mmHg (in consideration of contraindications!) may be aimed.A specific protocol for massive transfusion should be introduced and continued.Acidaemia should be prevented and treated by appropriate shock therapy.Loss of body temperature should be prevented and treated. Hypocalcaemia <0.9 mmol/l should be avoided and may be treated. For actively bleeding patients, packed red blood cells (pRBC) may be given at haemoglobin<10g/dl(0,62mmol/l). If massive transfusion is performed using fresh frozen plasma (FFP), a ratio of FFP to pRBC of 1:2 to 1:1 should be achieved.For treatment of hyperfibrinolysis after severe trauma the use of tranexamic acid should be considered at an early stage. Fibrinogen should be substituted at levels <1,5g/l (4,41μmol/l). Prothrombin complex concentrates may be helpfull for treatment of diffuse bleeding or anticoagulativemedikation. In acute bleeding, platelets may be transfused at a platet count <100000/μl. For diffuse bleeding or thrombocytopathic patients desmopressin might be a therapeutic option.If a factor XIII (FXIII) measurement is not promptly available, a factor XIII blind-dose should be considered in severe ongoing bleeding. The use of recombinant activated coagulation factor VII (rFVIIa) be considered if major bleeding persists despite standard attempts to control bleeding and best practice use of blood components., (© Georg Thieme Verlag Stuttgart · New York.)

Background: Coagulopathy associated with trauma and bleeding requires early administration of haemostatic agents. Solvent/detergent-treated plasma (S/D-plasma) requires thawing and its availability for clinical use is, therefore, delayed. The long-term stability of clotting factors in thawed S/D-plasma has not been thoroughly investigated. The purpose of this study was to evaluate stability of clotting factors and inhibitors in thawed S/D-plasma stored at 4 °C for 6 days., Materials and Methods: Clotting factor levels and bacterial contamination were investigated using 20 units of S/D-plasma. Fibrinogen, factor (F) II, FV, FVII, FVIII, FIX, FX, FXI, FXII, FXIII, antithrombin, von Willebrand antigen (VWF-Ag), plasmin inhibitor, protein C and free protein S were analysed over time., Results: After 6 days of storage the results were as follows: fibrinogen 270 mg/dL (-10 mg/dL, p=0.0204), FII 75% (-5%, p<0.0001), FV 88% (-14%, p<0.0001), FVII 81% (-24%, p<0.0001), FVIII 70% (-16%, p<0.0001), FIX 96% (-8, p<0.0001), FX 92% (-1%, p<0.0001), FXI 119% (-4%, p=0.3666), FXII 94% (-2%, p=0.3602), FXIII 89% (-1%, p 0.0019), free protein S 76% (-4%, p<0.0001), protein C 96% (+1%, p=0.0371), antithrombin 92% (-3%, p<0.0001), plasmin inhibitor 29% (-4%, p<0.0299), VWF-Ag 137% (+2%, p=0.2205). FVII and FVIII showed a critical drop of more than 20% or approached the lower quality assurance threshold after storage for more than 24 hours. No S/D-plasma showed bacterial contamination., Conclusion: All clotting factors in thawed S/D plasma remained stable for up to 24 hours when stored at 4 °C. Storage of thawed S/D plasma may improve the availability of this product in emergency situations.

Immediately after emergency caesarean section a 37 yr old patient suffered severe atonic bleeding requiring different operating procedures (Clipping of the uterine arteries) in combination with an uterotonic and haemostaseological medication as well as massive transfusion of blood components and recombinant factor VIIa. After a period of 17 days without any bleeding the patient presented to the emergency room with recurrent massive uterine bleeding. Transarterial embolization of the anterior bundles of the iliac arteries in combination with a second uterotonic and haemostaseological medication stopped the haemorrhage. Reasons and risk factors of a recurrent postpartum bleeding are discussed and a multidisciplinary algorithm for treatment is proposed., (© Georg Thieme Verlag Stuttgart · New York.)

Introduction: Octaplas® LG is a second-generation solvent/detergent-treated plasma that offers an additional safety benefit by prion elimination. The stability of clotting factors of the new S/D plasma after thawing has not been investigated yet. This study intended to measure the time course of fibrinogen, FII, FV, FVII, FVIII, FIX, PC, fPS and PI through storage at 2-6°C over 6 days., Materials and Methods: We investigated 20 plasma bags (five bags per blood group) and measured fibrinogen, FII, FV, FVII, FVIII, FIX, PC, fPS and PI immediately after thawing and after 2, 4, 6, 24, 48, 72, 96, 120 and 144 h storage at 2-6°C. Five separate plasma bags were thawed and stored at 2-6°C for microbiological assessment. After 6 days samples were drawn for blood cultures that were incubated for six more days., Results: After 6 days FII, FIX and PC showed no significant changes. FV (-16%, p<0.001), FVII (-19%, p<0.001), FVIII (-19%, p<0.001), FXI (-13%, p<0.0001) and fPS (-4%, p<0.0007) decreased significantly. PI levels were stable at 56%. The microbiological investigation showed no bacterial contamination., Conclusions: In Octaplas® LG plasma clotting factors decreased slightly through storage of 6 days. PI levels were remarkably higher and stable over time in the new Octaplas® LG. Stability of stored Octaplas® LG was limited by the decrease of FVIII to 53%, which may warrant storage up to 24h from a quality assurance point of view. This could result in reduced plasma wastage and costs for healthcare givers., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: To investigate the clinical relevance of specific volume criteria for hemorrhage in a patient population undergoing cardiac surgery with cardiopulmonary bypass (CPB)., Design: A retrospective analysis; postoperative hemorrhage was defined by a fixed set of criteria ≥200 mL/h in any 1 hour or part thereof, or (2) ≥2 mL/kg/h for 2 consecutive hours in the first 6 hours after surgery. Classification and regression tree (CART) analysis were used to validate the results of the specific volume criteria. Multivariate regression analysis was applied to investigate the association of specific volume criteria for hemorrhage with clinical outcomes., Setting: A university hospital., Participants: All adult cardiac surgery patients undergoing surgery with CPB at the authors' center in 2006., Interventions: None., Measurements and Main Results: A total of 1,188 patients underwent cardiac surgery, and 76 patients (6.4%) experienced postoperative hemorrhage according to the fixed criteria for blood loss. Blood loss as measured by these criteria was associated with a higher 30-day mortality (odds ratio [OR] = 2.9, p < 0.001), incidence of stroke (OR = 3.3, p = 0.0033), re-exploration (OR = 103.655, p < 0.0001), intensive care unit stay >72 hours (OR = 1.3, p < 0.0001), and mechanical ventilation >24 hours (OR = 3.4, p = 0.0002). The clinical relevance of these criteria is supported by CART analysis., Conclusions: Postoperative hemorrhage (drainage loss) exceeding 200 mL/h in 1 hour or 2 mL/kg for 2 consecutive hours occurring within 6 hours after cardiac surgery is associated with higher 30-day mortality and other postoperative complications. Further research is needed to validate these results., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Unlabelled: Rivaroxaban, the first direct factor-Xa inhibitor anticoagulant, has been approved for the prevention of venous thromboembolism in adult patients undergoing elective hip or knee replacement surgery, for stroke prophylaxis in patients with non-valvular atrial fibrillation and for the treatment of deep vein thrombosis. There is no requirement for coagulation monitoring with rivaroxaban in routine clinical practice. However, in certain clinical circumstances such as life-threatening bleeding or an emergency operation the measurement of the thromboplastin time with a sensitive reagent will deliver first information. A quantitative determination of rivaroxaban plasma concentration is possible using an anti-factor Xa assay. In the case of a patient under long-term anticoagulation with rivaroxaban requiring an elective surgery, a discontinuation of rivaroxaban 20 to 30 hours before the operation is sufficient to normalize the associated bleeding risk, as long as the renal and liver function is normal. A longer interval should be taken into consideration, when the patient presents a renal and liver impairment or is of a higher age. In the event of an emergency operation effective rivaroxaban concentrations might be present. Nevertheless, we advise against using a prophylactic dose of factor concentrates., Recommendations: From a clinical perspective, in the event of a minor bleeding we recommend a temporary discontinuation of rivaroxaban, whereas for clinically relevant major or severe bleeding events a mechanical compression or a limited surgical i.e. interventional treatment is required. Supportive measures such as the administration of blood products or tranexamic acid might be beneficial. In addition to haemodynamic supportive measures life threatening bleeding events demand a comprehensive haemostasis management, as well as the application of PCC.

Resolute and rapid action in obstetric emergencies is essential for the child and/or maternal survival. Therefore emergency caesarean section and the emergency actions for peripartal haemorrhage, shoulder dystocia, fetal bradycardia, hypertension and embolism should be interdisciplinarily coordinated. Interdisciplinary emergency concepts for the major complications could help to optimise their therapy taking structural conditions and legal requirements into account. Emergency concepts should include the alarm- procedure, communication, logistics, the priority steps in therapy as well as the analysis of the passed obstetric emergency. A regular interdisciplinary training of the major obstetric emergencies may help to avoid unnecessary loss of time., (© Georg Thieme Verlag Stuttgart · New York.)

In a national audit of elective orthopedic surgery conducted in the US, 30% of patients were found to have hemoglobin (Hgb) levels < 13 g/dl at preadmission testing. Preoperative anemia has been associated with increased mortality and morbidity after surgery, increased allogeneic blood transfusion therapy and increased rates of postoperative infection leading to a longer length of hospital stay. Because of the risks associated with allogeneic blood transfusions according to German law patients have to be offered the option of autologous transfusion if the risk associated with allogeneic blood transfusion is > 10%. However, one of these measures, the autologous blood donation, can exaggerate anemia and can increase the overall transfusion rates (allogeneic and autologous). As autologous procedures (autologous blood donation and cell salvage) are not always appropriate for anemic patients together with an expected shortage of blood and because preoperative anemia is associated with perioperative risks of blood transfusion, a standardized approach for the detection, evaluation and management of anemia in this setting was identified as an unmet medical need. A panel of multidisciplinary physicians was convened by the Society for Blood Management to develop a clinical care pathway for anemia management in elective surgery patients for whom blood transfusion is an option. In these guidelines elective surgery patients should have Hgb level determination at the latest 28 days before the scheduled surgical procedure. The patient target Hgb before elective surgery should be within the normal range (normal female ≥ 120 g/l, normal male ≥ 130 g/l). Laboratory testing should take place to further determine nutritional deficiencies, chronic renal insufficiency and/or chronic inflammatory diseases. Nutritional deficiencies should be treated and erythropoiesis-stimulating agent (ESA) therapy should be used for anemic patients in whom nutritional deficiencies have been ruled out and/or corrected.

Preoprative Anaemia is an independent risk factor in perioperative medicine. Furthermore, preoperative anaemia is associated with higher treatment costs and remains the main risk factor for the transfusion of packed red blood cells. However, transfusion of packed red blood cells is although life-saving in conditions of acute anaemia associated with higher mortality, morbidity and postoperative complications. The preoperative treatment of anaemia has been shown to improve postoperative outcome and transfusion requirements. Treatment of anemia as one pillar of patient blood management bears the potential to reduce costs to the national health system by prevention of complications and transfusion-associated morbidity. The economic impact of the treatment of preoperative anaemia versus the treatment with blood products requires prospective evaluation., (© Georg Thieme Verlag Stuttgart · New York.)

An increasing number of patients suffering from cardiovascular disease, especially coronary artery disease (CAD), are treated with aspirin and/or clopidogrel for the prevention of major adverse events. Unfortunately, there are no specific, widely accepted recommendations for the perioperative management of patients receiving antiplatelet therapy. Therefore, members of the Perioperative Haemostasis Group of the Society on Thrombosis and Haemostasis Research (GTH), the Perioperative Coagulation Group of the Austrian Society for Anesthesiology, Reanimation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society of Cardiology (ESC) have created this consensus position paper to provide clear recommendations on the perioperative use of anti-platelet agents (specifically with semi-urgent and urgent surgery), strongly supporting a multidisciplinary approach to optimize the treatment of individual patients with coronary artery disease who need major cardiac and non-cardiac surgery. With planned surgery, drug eluting stents (DES) should not be used unless surgery can be delayed for ≥12 months after DES implantation. If surgery cannot be delayed, surgical revascularisation, bare-metal stents or pure balloon angioplasty should be considered. During ongoing antiplatelet therapy, elective surgery should be delayed for the recommended duration of treatment. In patients with semi-urgent surgery, the decision to prematurely stop one or both antiplatelet agents (at least 5 days pre-operatively) has to be taken after multidisciplinary consultation, evaluating the individual thrombotic and bleeding risk. Urgently needed surgery has to take place under full antiplatelet therapy despite the increased bleeding risk. A multidisciplinary approach for optimal antithrombotic and haemostatic patient management is thus mandatory.

The importance of partial liver resection as a therapeutic option to cure hepatic tumors has increased over the last decades. This has been influenced on the one hand by advances in surgical and anesthetic management resulting in a reduced mortality after surgery and on the other hand by an increased incidence of hepatocellular carcinoma. Nowadays, partial resection of the liver is performed safely and as a routine operation in specialized centers. This article describes the pathophysiological changes secondary to liver failure and assesses the perioperative management of patients undergoing partial or extended liver resection. It looks in detail at the preoperative assessment, the intraoperative anesthetic management including fluid management and techniques to reduce blood loss as well as postoperative analgesia and intensive care therapy.

Introduction: Damage to dentoalveolar structures related to general anaesthesia is a well-known complication and may represent a relevant morbidity for affected patients. Central documentation of perioperative dentoalveolar injuries was performed since 1990 in the Department of Anaesthesiology and Intensive Care Medicine in cooperation with the Department of Oral and Maxillofacial Surgery at the Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum. Documentation of perioperative dentoalveolar injury consisted of anaesthesia charts, reports of the anaesthesiologists and consultant maxillofacial surgeons., Materials and Methods: Retrospective analysis of the data from 1990 to 2004 was performed according to this documentation with respect to incidence, matter, distribution of dental injury and therapeutic consequences., Results: Within 14 years 82 'dental injuries' with 103 affected teeth were documented in calculated 375,000 general anaesthesias. Incidence of 0.02% was very constant with an average of 5.5 events/year. Eighty-nine percent of the documented injuries occurred during scheduled operative procedures. Only 32.9% of the injuries took place during endotracheal intubation. In about 50% the injury was not related to intubation or extubation but happened during general anaesthesia. In 80% the dental injury was estimated by the anaesthesiologist as 'not avoidable'. In 83% pre-existing affection or structural injury of intraoral tissues was documented, in 32.7% of the affections sufficient therapy could be provided already during inhospital stay., Conclusion: Perioperative dentoalveolar injury is surely an annoying complication of general anaesthesia. However incidence is rare and seems to be unavoidable. Pre-existing damage to dentoalveolar structures is the main risk for additional injuries related to general anaesthesia. Adequate therapy can be provided by interdisciplinary concepts. There should be a fair balance between the benefit of the surgical procedure and the risk of dental injury related to general anaesthesia. Awareness of the problem and proper documentation are important factors for adequate management in liability cases., (© 2011 John Wiley & Sons A/S.)

A central area for induction of anesthesia (CAIA) is supposed to optimize processes of preoperative patient preparation for anesthesia. The purpose of this study was to assess whether the separation of the anesthesia process into anesthesia induction and anesthesia maintenance is associated with residents' job satisfaction. The central area for induction of anesthesia model (CAIA model) was prospectively compared to the conventional model of anesthesia being induced, maintained and ended by the same anesthetist. Quality of senior staff supervision for each day as well as workday satisfaction was additionally graded by a Likert-scale. More than 80% of residents considered their workday as satisfying or very satisfying, regardless of the model applied. Furthermore, work day satisfaction was significantly associated with the quality of supervision provided by the teaching staff. It was concluded that time and attention provided by the teaching staff rather than the anesthesia organisational model were the major determinants of workday satisfaction.

Aims: Little is known about long-term stability of clotting factors in dissolved human lyophilised plasma. This study evaluated clotting factor and inhibitor activity in reconstituted lyophilised plasma after storage for up to 6 days at 4 degrees C., Methods: Five samples from different lots of pooled lyophilised plasma (LyoPlas; German Red Cross Blood Transfusion Service West) were reconstituted. The activity of fibrinogen, factor II (FII), FV, FVII, FVIII, FIX, FX, FXI, FXII, FXIII, antithrombin, plasmin inhibitor, von Willebrand factor antigen, free protein S and protein C were determined immediately and at 2, 4, 6, 24, 48, 72, 96, 120 and 144 h after reconstitution. Tests for bacterial contamination were performed after 12, 72 and 144 h from each plasma bottle., Results: Storage at 4 degrees C for 6 h led to a decrease in the activity of FVIII (Delta -14.9%), FIX (Delta -6.9%) and FXI (Delta -6.3%), and an increase in the activity of plasmin inhibitor (Delta +10.2%). Storage for up to 6 days resulted in a further decrease in activity of FVIII (Delta -24.3%), FIX (Delta -13.4%) and FXI (Delta -22.9%), and, additionally, a decrease in the activity of FV (Delta -15.0%), fibrinogen (Delta -6.9%) and plasmin inhibitor (Delta -17.5%). Other factors and inhibitors, with exception of protein C (Delta +8.2%), remained almost unchanged over time. Blood cultures were sterile and showed no bacterial growth., Conclusions: The activity of all measured coagulation factors and inhibitors in a time course of up to 6 days met required quality standards. Further in vivo testing is required to demonstrate safety and efficacy of extended clinical use of refrigerated reconstituted lyophilised plasma.

Introduction: Antifibrinolytic agents are commonly used during cardiac surgery to minimize bleeding. Because of safety concerns, aprotinin was withdrawn from the market in 2007. Since then, tranexamic acid (TXA) has become the antifibrinolytic treatment of choice in many heart centers. The safety profile of TXA has not been extensively studied. Therefore, the aim of this study was to evaluate safety and efficiency of TXA compared with aprotinin in cardiac surgery., Methods: Since July 1, 2006, TXA has been administered at a dose of 50 mg/kg tranexamic acid before cardiopulmonary bypass (CPB) and 50 mg/kg into the priming fluid of the CPB. Prior to this, all patients were treated with aprotinin at a dose of 50,000 KIU per kilogram body weight. Safety was evaluated with mortality, biomarkers, and the diagnosis of myocardial infarction, ischemic stroke, convulsive seizures, and acute renal failure in the intensive care unit (ICU), intermediate care unit (IMCU), and hospital stay. Efficiency was evaluated by the need for transfusion of blood products and total postoperative blood loss., Results: After informed consent, 893 patients were included in our database (557 consecutive patients receiving aprotinin and 336 patients receiving TXA). A subgroup of 320 patients undergoing open-heart procedures (105 receiving TXA and 215 receiving aprotinin) was analyzed separately. In the aprotinin group, a higher rate of late events of ischemic stroke (3.4% versus 0.9%; P = 0.02) and neurologic disability (5.8% versus 2.4%; P = 0.02) was found. The rate of postoperative convulsive seizures was increased in tendency in patients receiving TXA (2.7% versus 0.9%; P = 0.05). The use of TXA was associated with higher cumulative drainage losses (PANOVA < 0.01; Ptime < 0.01) and a higher rate of repeated thoracotomy for bleeding (6.9% versus 2.4%; P < 0.01). In the subgroup of patients with open-chamber procedures, mortality was higher in the TXA group (16.2% TXA versus 7.5% aprotinin; P = 0.02). Multivariate logistic regression identified EURO score II and CPB time as additional risk factors for this increased mortality., Conclusions: The use of high-dose TXA is questioned, as our data suggest an association between higher mortality and minor efficiency while the safety profile of this drug is not consistently improved. Further confirmatory prospective studies evaluating the efficacy and safety profile of TXA are urgently needed to find a safe dosage for this antifibrinolytic drug.