blood conservation techniques and perioperative planning part 3 · 2008. 10. 15. · k.r part 3 of...

Helping Hands for Blood Conservation Techniques and Perioperative Planning

Part 3 May 2001

INTRAOPERATIVE TREATMENTS Table of Contents

INTRAOPERATIVE TREATMENT ........................................................................... 13

I. HEMOSTATIC AGENTS............................................................................................................................... 13 A. Collagen in Surgery and Hemostasis ...................................................................................................... 13

1. Collagen for Testing Platelet Aggregation ................................................................................ 13 2. Collagen Hemostat in Auto,transfusion use of Leukocytefilters Pall RC100............................ 13

A. Microfibrillar-Collagen (Avitene) as local Hemostatic method ......................................................... 14 1. Collagen and Thrombin for Hemostasis after Sternotomy ........................................................ 14 2. Collagen and Antibiotic primed Fibrin Glue for Sternotomy Wound ....................................... 14 3. Collagen in Splenic Laseration.................................................................................................. 14 4. Collagen In Hepatic injury......................................................................................................... 15 5. Collagen Sponges ...................................................................................................................... 15

B. Collagen as Biodegradable Carrier (CBC) ......................................................................................... 15 1. CBC for Antibiotics................................................................................................................... 15

a) CBC Gentamycin in Orthopedic Surgery ............................................................................. 15 b) CBC Gentamycin in Abdominal and Thoracic Surgery ....................................................... 16

2. CBC for Glucosteroids .............................................................................................................. 17 3. CBC for Proteins ....................................................................................................................... 17 4. Biodegradable Embolization Coils (BEC)................................................................................. 17

C. Collagen as Biomaterial in Surgery.................................................................................................... 18 1. Collagen Graft Materials ........................................................................................................... 18 2. Collagen Biomaterials in Poland ............................................................................................... 18 3. Collagen Coated Vascular Prostheses........................................................................................ 18 4. Collagen for Esophageal Prostheses .......................................................................................... 20 5. Collagen and Hydroxylapatit for Osseous Defects .................................................................... 21 6. Collagen as a Biomatrix for Chondrocytes................................................................................ 21 7. Bio Prosthetic Heart Valves (BPHVs)....................................................................................... 22

D. Collagen in Dermatologic Wounds .................................................................................................... 22 1. In Wounds after Biopsy or Extirpation as Hemostatics ............................................................. 22 2. Other Collagen "Alginate" in superficial Wounds (Diabetic Foot Ulcer).................................. 23

E. Collagen in Laparoscopic (LS) Surgery for Hemostasis..................................................................... 24 1. Collagen Intraoperative in LS.................................................................................................... 24 2. Collagen Sprayable Hemostat.................................................................................................... 24

B. Collagen as Bulking Agents .................................................................................................................... 24 A. Collagen in Incontinence.................................................................................................................... 24

1. Collagen as Reconstructive Agent General Aspects.................................................................. 24 2. Collagen injections for Urinary Incontinence as minimi-invasive Surgery............................... 26

a) GAX for Vesicouretral Reflux.............................................................................................. 26 b) Female Incontinence GAX ................................................................................................... 28 c) Male Incontinence GAX....................................................................................................... 31

K.R Part 3 of Helping Hands of Blood Conservation Techniques, May 2001 2

d) Children with Reflux ............................................................................................................ 33 3. GAX for Fecal Incontinence...................................................................................................... 34

a) Glutaraldehyde cross-Linked Collagen................................................................................. 34 4. GAX for Treatment of Laryngeal Dysfunction ......................................................................... 35

B. Complications of Injection Therapy ................................................................................................... 38 1. GAX Complication Urethral Mucosa Prolaps ........................................................................... 38 2.GAX induced Allergic Reactions, Sterile Abscesses and Pulmonary Embolism ....................... 38

C. Collagen for Puncture Site Closure ......................................................................................................... 39 A. Function and ways of using it............................................................................................................. 39

1. Collagen Plugging of Vascular Leaks ....................................................................................... 39 a) Puncture Site Plugging.......................................................................................................... 39 b) Arterial Sealing Vasoseal ..................................................................................................... 40 c) Arterial Sealing with VHD or HPCD Device? ..................................................................... 43

2. Collagen Puncture Closure COST /Benefits.............................................................................. 46 3. Collagen enhanced Fibrin Sealant For Plugging at Puncture Site ............................................. 47 4. Collagen Plugging in Anticoagulated Patients .......................................................................... 47 5. Collagen plug for High Risk Biopsies ....................................................................................... 49

a) Renal Biopsy in Coagulopathic Patients............................................................................... 49 B. Collagen Plugging Complications ...................................................................................................... 49

1. General Aspects of Complications ............................................................................................ 49 a) Angio-Seal Induced Complications Stenosis, Occlusion or Peripher Embolism.................. 49 b) VasoSeal induced Groin Complications ............................................................................... 49 c) Angio Seal induced Femoral Artery Occlusion .................................................................... 50 d) VasoSeal induced Collagen Embolism................................................................................. 51

II. HEMOSTATIC DRUGS ............................................................................................................................... 51 A. Meta-analysis for Hemostatic drug in Cardiac Surgery ..................................................................... 51

"9 Meta-Analytic Articles"................................................................................................................. 51 A. Epsilon-Aminocaproic Acid (EACA) ....................................................................................................... 55

A. Function and Fields of Use................................................................................................................. 55 1. EACA General Aspects ............................................................................................................. 55

a) Plasma EACA Concentrations.............................................................................................. 55 b) Enzymatic Plasmin Inhibition............................................................................................... 56 c) EACA Cost/Benefit Calculations ......................................................................................... 56

2. EACA Use and Dosage Regime ................................................................................................ 58 a) EACA Prophylactic .............................................................................................................. 58 b) EACA High Dosage ............................................................................................................. 60 c) EACA Low Dosage .............................................................................................................. 60 d) EACA esters as Transdermal Penetration Enhancing Agents .............................................. 61

3. EACA in Cardiac Surgery ......................................................................................................... 61 a) Children ................................................................................................................................ 61 b) Adults ................................................................................................................................... 63

4. EACA in Liver Surgery ............................................................................................................. 68 5. EACA in Ophtalmologic use ..................................................................................................... 69 6. EACA in Bleeding Disorders .................................................................................................... 70

a) General Aspects of Bleeding Disorders ................................................................................ 70 b) EACA in Amyloidosis.......................................................................................................... 71 c) EACA in Decreased Type 1 Plasminogen Activator Inhibitor Activity ............................... 72 d) EACA in Tissue-Type Plasminogen Activator induced Blood loss .................................... 72 e) EACA in C1 Inhibitor Deficiency ........................................................................................ 72 f) EACA in Hemophilia ............................................................................................................ 73

1) Aquirred Hemophilia ....................................................................................................... 73 2) Hereditary Hemophilia .................................................................................................... 73

g) EACA in von Willebrandt Disease....................................................................................... 74 h) EACA in Kasabach-Merrit Syndrome.................................................................................. 75 i) EACA in Klippel-Trenaunay Syndrome ............................................................................... 77 j) EACA in Factor VIII Deficiency........................................................................................... 77 k) EACA in DIC ....................................................................................................................... 79 l) EACA for Glanzmann's Thrombasthenia .............................................................................. 79

7. EACA in Renal Disease............................................................................................................. 80


a) Nephrotic Syndrome and Henoch-Schonlein Syndrome ...................................................... 80 b) Anti GBM Nephritis ............................................................................................................. 80

8. EACA in Neurosurgery ............................................................................................................. 81 a) EACA Early Aneurysm Surgery Reducing The Risk of Rebleeding.................................... 81 b) EACA in Cranial Arteriovenous Fistulae ............................................................................. 82

9. EACA in Bleeding of Laparoscopic Surgery............................................................................. 83 10. EACA in Gastrointestinal Bleeding (Radiation Gastritis) ....................................................... 83 11. EACA in Profound Hypothermia ............................................................................................ 84 12. EACA in Thrombocytopenia ................................................................................................... 84 13. EACA in Emergency Surgery.................................................................................................. 85 14. EACA in infants on ECMO..................................................................................................... 85 15. EACA in Hemodilutional Anesthesia..................................................................................... 85 16. EACA and Angiooedema ........................................................................................................ 87

B. EACA induced Complications ........................................................................................................... 87 1. Insoluble Blood Clot in the Renal Pelvis................................................................................... 87 2. EACA Intravascular Thrombosis............................................................................................... 87

a) Thromboses in Adults Fatal Pulmonary Embolism........................................................... 87 b) Thromboses in Children Fatal Aortic Thrombosis............................................................ 88

3. EACA induced Rhabdomyolysis ............................................................................................... 88 4. EACA induced Hyperkalemia ................................................................................................... 89 5. EACA induced Dermatitis ......................................................................................................... 89 6. EACA induced Hyperkalemia ................................................................................................... 90

B. Tranexamic Acid (TA)............................................................................................................................... 90 A. Function and Fields of Use................................................................................................................. 90

a. TA General Aspects and Dosing .................................................................................................... 90 1. TA Prophylactic......................................................................................................................... 92 2. TA Low Dose ............................................................................................................................ 93 3. TA High Dose............................................................................................................................ 95 4. TA Topical use. ......................................................................................................................... 97 5. TA Indications ........................................................................................................................... 97

b. TA in Cardiac Surgery ................................................................................................................... 98 1. TA in Hypothermic Anesthesia ................................................................................................. 98 2. TA in Cardiac and Coronary Surgery ........................................................................................ 98

a) TA in Primary Surgery ......................................................................................................... 98 b) TA in Cyanotic Children .................................................................................................... 103 c) TA in Repeat Cardiac Surgery............................................................................................ 104

1) TA Repeat Surgery Adults............................................................................................. 104 2) TA Repeat Surgery Children ......................................................................................... 105

3. TA in Valve Replacement Surgery.......................................................................................... 106 4. TA for Aortic Dissection ......................................................................................................... 108 5. TA for High Risk Cardiac Surgery .......................................................................................... 108

c. TA Gel locally in Epistaxis........................................................................................................... 109 d. TA in Orthopedic Surgery ............................................................................................................ 110

1. TA in Orthopedic Surgery General Aspects ............................................................................ 110 2. TA in Total Knee Arthroplasty................................................................................................ 113 3. TA in Total Hip Replacement................................................................................................. 116 4. TA in Reconstructive Cartilage Surgery.................................................................................. 117

e. TA in Oncology ............................................................................................................................ 117 f. TA in Leukemia ............................................................................................................................ 120

1. TA in Promyelocytic Leukemia............................................................................................... 120 2. TA in Acute Myeloid Leukemia.............................................................................................. 121

g. TA in Hemostatic Disorders......................................................................................................... 121 1. TA in DIC................................................................................................................................ 121 2. TA in Thrombocytopenia ........................................................................................................ 123 3. TA in Glanzmanns Thrombasthenia....................................................................................... 124 4. TA in Hemophiliacs................................................................................................................. 125

a) TA In Hemophiliacs General Aspects. ............................................................................... 125 b) TA in Hemophilia A........................................................................................................... 126 c) TA in Hemophilia B ........................................................................................................... 127

5. TA in Christmas Disease (Factor IX Deficiency) .................................................................... 129


6. TA in Factor XI Deficiency..................................................................................................... 129 7. TA in von Willebrand's Syndrome .......................................................................................... 130

a) TA in von Willebrandt Disease........................................................................................... 130 b) TA in Factor VIII inhibitor von Willebrandt-like Syndrome ............................................. 130

8. TA in Plasminogen Activator Inhibitor-1 (PAI-1) Deficiency ................................................ 131 9. TA in Alpha 2 Plasmin Inhibitor Deficiency........................................................................... 132 10. TA in Kasabach-Merrit Syndrome ........................................................................................ 132 11. TA in Klippel-Trenaunay-Weber Syndrome ......................................................................... 133 12. TA in Bernard-Soulier Syndrome.......................................................................................... 133

h. TA in Gynecology and Obstetrics ................................................................................................ 134 1. TA in Gyn/Obstr.General Aspects........................................................................................... 134 2. Dysfunctional Uterine Bleedings............................................................................................. 135

a) TA in Idiopathic Menorrhagia ............................................................................................ 136 b) TA in Ovulatory Menorrhagia ............................................................................................ 139 c) TA for Fibrinoid induced Hemorrhage and Dysfunctional Bleeding.................................. 141

3. TA in Pregnancy and after ....................................................................................................... 142 i. TA in Liver Transplantation.......................................................................................................... 143 j. TA in Angioedema ........................................................................................................................ 145

1. Hereditary Deficiency of C1 Esterase Inhibitor (C1-INH) ...................................................... 145 a) Type I Angioedema (HAE)................................................................................................. 146 b) Type II Angioedema........................................................................................................... 148

2. Treatment with C1-Concentrate and TA.................................................................................. 148 3. TA in Acquired Angioedema(AAE)........................................................................................ 149

k. TA for Patients on Anticoagulation subjected to Oral Surgery .................................................... 151 1. TA in Oral Surgery General Aspects ....................................................................................... 151 2. TA Mouth-Washings in Oral Surgery ..................................................................................... 152 3. TA in Dentistry........................................................................................................................ 154

l. TA in Angiodysplasias .................................................................................................................. 155 m. TA for Gastric Antral Vascular Ectasias(GAVE) ....................................................................... 155 n. TA in Gastric and Gastro Intestinal Bleeding............................................................................... 156 o. TA for Hemorrhage in Surgical Repair of Congenital Diaphragmatic Hernia(CDH) .................. 156 p. TA for Breast Surgery .................................................................................................................. 157 q. TA in Ophtalmologic Hyphema ................................................................................................... 157 r. TA in Anaphylactic Shock ............................................................................................................ 159 s. TA in Multiple Cholesterol Embolization Syndrome (MCES)..................................................... 160 t. TA in Rheumatoid Arthritis .......................................................................................................... 160 u. TA for Hemoptysis in Cystic Fibrosis Patients ............................................................................ 161 v. TA in Bleedings of Chronic Renal Failure (CRF) and Uremia .................................................... 161 x. TA in Neurosurgery...................................................................................................................... 162

1. TA in Intracranial Aneurysmal Surgery TA and Calcium Chanel Blockers............................ 162 2. TA for Subarachnoid Hemorrhage (SAH)............................................................................... 162

B. TA Complications ............................................................................................................................ 164 1. TA induced Allergy and Exzema............................................................................................. 164 2. TA induced Ophtalmopathia Central Retinal Arterial Occlusion and Venous Stasis .............. 164

a) TA Induced Central Retinal Artery Occlusion ................................................................... 164 b) TA Induced Central Venous Stasis Retinopathy ................................................................ 165 c) TA associated Ligneous Conjunctivitis .............................................................................. 165

3. TA and Microscopic Hematuria , Clot formation, Renal Failure. ........................................... 165 4. TA induced Massive Pulmonary Embolism ............................................................................ 166 5. TA induced Deep Vein Thrombosis ........................................................................................ 166 6. TA induced Thrombosis of Sinus Sagittalis Superior.............................................................. 166 7. TA induced Fatal Thromboembolism...................................................................................... 166 8. Ta induced Acute Renal Cortical Necrosis.............................................................................. 167 9. Ta induced Epilepticogenic Effects ......................................................................................... 167

C. APROTININ ............................................................................................................................................ 167 A. Function and Fields of Use............................................................................................................... 167

1. APRO General Indications and Aspects .................................................................................. 167 a) APRO General Effects and Efficacy................................................................................... 167 b) APRO induced inhibition of Plasmin ................................................................................. 169 c) APRO effect on Bradykinin induced Vascular Permeability.............................................. 171


d) APRO effect on Anticoagulation........................................................................................ 171 e) APRO and EPO better Coagulation in Cardiac Surgery..................................................... 172

2. APRO Antiinflammatory Function Postperfusion Syndrome .............................................. 173 3. APRO in Cytocine induced Nitric Oxide Synthetase Expression............................................ 178 4. APRO in Profound Hypothermia............................................................................................. 179 5. APRO Costs/ Benefit............................................................................................................... 181 6. APRO Dosage formulas .......................................................................................................... 185

a) APRO High Dose ............................................................................................................... 185 b) APRO Low Dose ................................................................................................................ 191 c) APRO Post Operative use................................................................................................... 194 d) APRO Prophylactic Use ..................................................................................................... 195 e) APRO Dosage in Children.................................................................................................. 198 f) APRO Topical Use.............................................................................................................. 198

1) APRO Topical in Coronbary Artery Bypass Surgery .................................................... 198 7. APRO and Sepsis..................................................................................................................... 199 8. APRO may neutralize Heparin ................................................................................................ 201 9. APRO may neutralize Streptokinase ....................................................................................... 202 10. APRO in Transplantation Surgery......................................................................................... 203

a) APRO for Heart Transplantation ........................................................................................ 203 b) APRO for Lung Transplantation ........................................................................................ 205 c) APRO in Livertransplantation ............................................................................................ 207

11. APRO in Vascular Surgery.................................................................................................... 211 12. APRO in Cardiac Surgery ..................................................................................................... 213

a) APRO Cardiac General Aspects ......................................................................................... 213 b) APRO in Complex Malformations ..................................................................................... 217 c) APRO in Children for Congenital Heart Disease ............................................................... 218

1) APRO Children Cardiac Surgery General Aspects........................................................ 218 2) APRO Children REDO Surgery .................................................................................... 220

d) APRO in Adult REDO Cardiac Surgery............................................................................. 221 e) APRO Coronary Bypass Surgery........................................................................................ 223 f) APRO for Ruptured AAA................................................................................................... 224 g) APRO for Bleeding during ECLS ...................................................................................... 224

13. APRO in Orthopedic Surgery................................................................................................ 225 a) APRO in Orthopedic Surgery General Aspects .................................................................. 225 b) APRO in Total HipReplacement Surgery........................................................................... 225 c) APRO in Spinal Fusion Surgery......................................................................................... 227

14. APRO Abdominal Surgery .................................................................................................... 228 15. APRO and Coagulopathies .................................................................................................... 229

a) APRO in Coagulation Dysfunction .................................................................................... 229 b) APRO may Neutralize Aspirin ........................................................................................... 230 c) APRO Thrombocyte Function ............................................................................................ 232 d) APRO in Thrombocytopenias............................................................................................. 235

B. APRO Complications ....................................................................................................................... 237 1. General aspects of APROAdverse Reactions in 2.8% Test Dose 10.000 KIU! ................... 237 2. APRO induced Hypersensitivity Reactions ............................................................................. 238

a) Incidence of Hypersensitivity ............................................................................................. 238 b) APRO induced Anaphylactic Shock................................................................................... 239

3. APRO induced Acute Respiratory Failure ARDS ................................................................... 239 4. APRO induced Vein Graft Occlusion and Myocardial Infarction ........................................... 240 5. APRO Induced Fatal Pulmonary Embolism............................................................................ 240 6. APRO induced Fatal Thromboembolism in Promyelocytic Leukemia ................................... 240

D. DESMOPRESSIN (DDAVP) .................................................................................................................. 241 A. Function and Fields of Use............................................................................................................... 241

1. DDAVP in Surgery General Aspects....................................................................................... 241 a) DDAVP General Aspects ................................................................................................... 241 b) DDAVP and effect on Platelet Function............................................................................. 241

2. DDAVP Dosage ...................................................................................................................... 242 a) DDAVP intra Venous Haemostatic Dosage ....................................................................... 242 b) DDAVP Subcutaneous Dosage .......................................................................................... 242 c) DDAVP intranasal Dosage ................................................................................................. 243


d) DDAVP Oral tablett dosage ............................................................................................... 243 3. DDAVP in Cardiac Surgery .................................................................................................... 245

a) DDAVP in Adult Cardiac Surgery ..................................................................................... 245 b) DDAVP in Cardiac Surgery of Children ............................................................................ 249

4. DDAVP in Orthopedic Surgery............................................................................................... 250 a) DDAVP in Spinal Surgery.................................................................................................. 250 b) DDAVP in Hip Surgery...................................................................................................... 252 c) DDAVP in Knee Arthroplasty ............................................................................................ 253 d) DDAVP in Plastic Reconstructive Surgery ........................................................................ 253 e) DDAVP in Orthognatic Surgery......................................................................................... 254

5. DDAVP in Thermal Injury ...................................................................................................... 254 6. DDAVP in Hematologic Malignancy...................................................................................... 255 7. DDAVP in Dysfunctional Uterine Bleedings .......................................................................... 256 8. DDAVP in Thrombocytopathies ............................................................................................. 257 9. DDAVP in Coagulopathies and Bleeding Disorders ............................................................... 261 10. DDAVP in Factor XI Deficiency........................................................................................... 267 11. DDAVP in von Willebrandts Disease ................................................................................... 268

a) DDAVP in Hereditary von Willebrandt Disease ................................................................ 268 1) DDAVP in von Willebrand Disease General Aspects .......................................... 268 2) DDAVP in von Willebrand Disease Type 1 and 2 a ............................................. 270 3) DDAVP in von Willebrand Disease Type 2b or 3 in severe Thrombocytopenia........................................................................................................................................... 271 4) DDAVP in Adenotonsillectomy of von Willebrandt children............................. 273

b) DDAVP in Acquired von Willebrandt Disease .................................................................. 274 12. DDAVP in Hemophiliacs ...................................................................................................... 276

a) DDAVP in Hemophilia General Aspects............................................................................ 276 b) DDAVP in Hemophilia A................................................................................................... 278 c) DDAVP in Hemophilia B ................................................................................................... 279 d) DDAVP and acquired Hemophilia ..................................................................................... 280

13. DDAVP in Sickle Cell Disease ............................................................................................. 281 14. DDAVP for Plasmaexpander induced Coagulopathy............................................................ 282

a) DDAVP and Plasma Expander induced Coagulopathy General Aspects ........................... 282 b) DDAVP and Hydroxyethyl Starch induced Coagulopathy................................................. 282 c) DDAVP and Dextran induced Coagulopathy ..................................................................... 285

15. DDAVP in Ehlers-Danlos Syndrome .................................................................................... 286 16. DDAVP for Uremic Bleeding................................................................................................ 287 17. DDAVP in Amyloidosis Hemorrhage ................................................................................... 289 18. DDAVP in Vascular surgery ................................................................................................. 289 19. DDAVP in Aspirin induced Bleeding ................................................................................... 290 20. DDAVP in Hepatic surgery ................................................................................................... 292 21. DDAVP in Neurosurgery ...................................................................................................... 293

a) DDAVP for Aneurysmal Subarachnoid Haemorrhage ....................................................... 293 B. DDAVP Complications .................................................................................................................... 293

1. DDAVP Induced Fatal Complications General Aspects, Pulmonary Edema .......................... 293 2. DDAVP induced Thrombocytopenia and Subdural Hematoma .............................................. 294 3. DDAVP induced Venous Thrombosis and Pulmonary Embolism .......................................... 295 4. DDAVP induced Water Intoxication, Hyponatremia and Tonic Clonic Seizure..................... 295

III. VASOACTIVE AGENTS .......................................................................................................................... 300 A. VASOPRESSIN (AVP)............................................................................................................................ 300

A. Function and Use.............................................................................................................................. 300 1. AVP General aspects ............................................................................................................... 300 2. AVP for Variceal Bleeding...................................................................................................... 303 3. AVP for Diverticular Bleeding ................................................................................................ 304 4. AVP for Vasodilatory Shock Hypotension after Cardiac Surgery........................................... 305 5. AVP in Major Abdominal Surgery.......................................................................................... 306 6. AVP in Gynecologic Surgery .................................................................................................. 308 7. AVP in Plastic Surgery............................................................................................................ 311 8. AVP for Gastric Wounds......................................................................................................... 312 9. AVP levels in Thermal injury.................................................................................................. 312


B. AVP Complications.......................................................................................................................... 315 1. AVP induced Pulmonary edema.............................................................................................. 315 2. AVP induced Myocardial Infarction........................................................................................ 315 3. AVP Induced Hypotension and Bradycardia........................................................................... 315

B. TERLIPRESSIN (TLP) ........................................................................................................................... 316 A. Function and Use.............................................................................................................................. 316

1. TLP general Aspects................................................................................................................ 316 2. TLP in Variceal Bleeding ........................................................................................................ 318 3. TLP in Burns ........................................................................................................................... 324 4. TLP in ORL Surgery and Bleeding ......................................................................................... 325 5. TLP in Gynecologic Surgery ................................................................................................... 325 6. TLP for Hepatorenal Syndrome............................................................................................... 327 7. TLP combination with Glycerin trinitrate for Acute GI Hemorrhage ..................................... 329

B. TLP Complications........................................................................................................................... 329 1. TLP induced Hypokalemia ...................................................................................................... 329 2. TLP induced Myocardial Infarction ........................................................................................ 329 3. TLP induced Rhabdomyolysis................................................................................................. 330

C. SOMATOSTATIN................................................................................................................................... 330 A. Function and Use.............................................................................................................................. 330

1. Somatostatin General Aspects ................................................................................................. 330 2. Somatostatin for Variceal Bleeding......................................................................................... 330 3. Somatostatin and GI Surgery................................................................................................... 332 4. Somatostatin for Peptic Ulcer Bleeding................................................................................... 333 5. Somatostain for Persisting postoperaive Chylothorax ............................................................. 334 6. Somatostatin for Pancreatic Tumors........................................................................................ 335 7. Somatostatin in Pancreatic Surgery ......................................................................................... 335 8. Somatostatin Analogue for Neuroblastomas ........................................................................... 336 9. Somatostatin for Leukemia ? ................................................................................................... 336

B. Somatostatin Complications ............................................................................................................. 337 1. Somatostatin induced Sleep Disturbations............................................................................... 337 2. Somatostatin Induced Hepatic Injury ...................................................................................... 337

D. OCTREOTIDE ........................................................................................................................................ 337 A. Function and Use.............................................................................................................................. 337

1. Octreotide and Surgery General Aspects................................................................................. 337 a) Octreotide General Aspects ................................................................................................ 337 b) Octreotide In Dumping Syndrome...................................................................................... 338 c) Octreotide Radioimmuno Targeting in Cancer Therapy..................................................... 338

2. Octreotide in Digestive Surgery .............................................................................................. 339 3. Octreotide in Malignant Neuroendocrine Tumors ................................................................... 340 4. Octreotide for Inoperable Bowel Obstruction.......................................................................... 345 5. Ocreotide for Variceal Bleeding .............................................................................................. 346 6. Octreotide for Necrolytic Migratory Erythema ....................................................................... 350 7. Octreotide after Coronary Angioplasty.................................................................................... 350 8. Octreotide in Bleeding due to Angiodysplasia ........................................................................ 351 9. Octreotide in Pancreatitis......................................................................................................... 351 10. Octreotide after ERCP No!.................................................................................................... 354 11. Octreotide for Pancreatic Fistulas.......................................................................................... 354 12. Octreotide for Intestinal Radiation Injury.............................................................................. 355 13. Octreotide for Carcinoid Tumors........................................................................................... 355 14. Octreotide for Islet Cell Tumors............................................................................................ 358 15. Octreotide for Pancreatic Cancer ........................................................................................... 359 16. Octreotide for Malignat Thymomas ...................................................................................... 359 17. Octreotide Crush Syndrome of Polytrauma Patients ............................................................. 360

B. Octreotide Complications ................................................................................................................. 360 1. Octreotide induced Hepatic Injury........................................................................................... 360 2. Octreotide induced Bradycardia .............................................................................................. 362 3. Octreotide induced Hyperkalemia ........................................................................................... 362 4. Octreotide induced negative effects on Wound healing .......................................................... 363

a).Colonic Anastomoses ......................................................................................................... 363 b) Dorsal Midline Wound Healing.......................................................................................... 363


E. LANREOTIDE......................................................................................................................................... 363 A. Lanreotide Function and Use ........................................................................................................... 363

1. Lanreotide General Aspects..................................................................................................... 364 a) Lanreotide General Aspects................................................................................................ 364 b) Lanreotide in Severe Chronic Renal Insufficiency............................................................. 366 c) Lanreotide effects in Healty Volunteers ............................................................................. 367 d) Lanreotide inhibits MAP Kinase Activation ...................................................................... 367 e) Lanreotide ILGF-I Inhibition............................................................................................. 368 f) Lanreotide Induced GH Inhibition ...................................................................................... 369 g) Lanreotide induced Immunomodulatory Action................................................................. 370

2. Lanreotide in Pituitary Adenomas ........................................................................................... 370 a) Lanreotide in Pituitary Adenomas General Aspects ........................................................... 371 b) Lanreotide in Acromegaly .................................................................................................. 373

1) Lanreotide in Acromegaly General Effects ................................................................... 373 2) Lanreotide Effects on Gall-Bladder Motility in Acromegaly ........................................ 377 3) Lanreotide Effects on Joint Thickening in Acromegaly ................................................ 378 4) Lanreotide induced Cardiac Effects in Acromegaly ...................................................... 379

3. Lancreotide in Breast Cancer................................................................................................... 379 4. DOTA-Lancreotide in Tumor Diagnosis and Therapy ............................................................ 382 5. Lanreotide in Mauritius ........................................................................................................... 383 6. Lanreotide in Gastrointestinal Neuroendocrine Tumors.......................................................... 384

a) Lanreotide in Gastrointestinal Neuroendocrine Tumors General Aspects.......................... 384 b) Lancreotide for Gastroenteropancreatic Tumors ................................................................ 385 c) Lancreotide for Carcinoid Syndrome.................................................................................. 388

7. Lanreotide in Refractory Prostate Cancer Therapy.................................................................. 390 8. Lanreotide in Pancreatic Cancer .............................................................................................. 391 9. Lanreotide in Hepatocellular Cancer ....................................................................................... 392 10. Lanreotide in Pediatric Oncology .......................................................................................... 392 11. Lanreotide for Dumping Syndrome....................................................................................... 393 12. Lanreotide in TED................................................................................................................. 393 13. Lanreotide in IDDM .............................................................................................................. 394

B. Lanreotide Complications................................................................................................................. 395 1. Lanreotide induced Pain at Injection site................................................................................. 395 2. Lanreotide induced Gastrointestinal Symptoms ...................................................................... 395 3. Lanreotide induced Gall Stones............................................................................................... 395

F. OXYTOCIN.............................................................................................................................................. 395 A. Function and Use.............................................................................................................................. 395

1. General Aspects of Effects of Oxytocin .................................................................................. 395 a) Oxytocin General Aspects .................................................................................................. 395 b) Oxytocin Renal effects ....................................................................................................... 397 c) Oxytocin Receptors ............................................................................................................ 399 d) Oxytocin mode of Administration : Continuous Infusion or Pulsatile ............................... 401 e) Oxytocin for Active-phase Labor Arrest ............................................................................ 401

2. Oxytocin after Delivery ........................................................................................................... 404 3. Oxytocin for Musculocutaneous Flaps .................................................................................... 405 4. Oxytocin for Uterine Rupture.................................................................................................. 405 5. Oxytocin in Endometrial Ablation........................................................................................... 406 6. Oxytocin Receptor Blocking Agents ....................................................................................... 407

a) Atosiban for Oxitocin Antagonism..................................................................................... 407 7. Oxytocin in Post Partum Uterine Atonia ................................................................................. 411

B. Oxytocin Complications ................................................................................................................... 412 1. Oxytocin Induced Uterine Rupture.......................................................................................... 412 2. Oxytocin Induced Aseptic Synovitis and Tendon Rupture...................................................... 413 3. Oxytocin induced Ventricular Tachycardia ............................................................................. 413

G. Prostaglandin E2 Analoques................................................................................................................... 413 A. Prostaglandins General Aspects ....................................................................................................... 413

1. PG E2 General Aspects ........................................................................................................... 413 a) Prostaglandin E2 Regulates M-CSF secretion .................................................................... 413 b) PGE2 Receptors regulates Tumor Necrosis Factor induced ICAM-1 Expression.............. 414 c) PGE2 in Abortion ............................................................................................................... 415


d) PGE2 in Tubal Pregnancy instead of Surgery .................................................................... 417 1) PGE2 in Ectopic Pregnancy........................................................................................... 417 2) Prostaglandin F2 alpha Local Istillation ........................................................................ 419 3) Combination Therapy in Tubal Pregnancy and Induced Abortion ................................ 422 4) Laparoscopic therapy for Ectopic Pregnancy ................................................................ 423 5) Single Dose Metotrexate................................................................................................ 425 6) Anti-Progesterones "Mifepristone" for Ectopic Pregnancy ........................................... 429 7) Arterial Embolization for Control of Obstetric Hemorrhage ......................................... 433

e) PGE2 in Atonic Bleeds ....................................................................................................... 435 2. Prostanoid EP(1)/EP(3) receptor agonist Sulprostone ............................................................. 438

a) Sulprostone General Aspects .............................................................................................. 438 b) Sulprostone for Post Partum Hemorrhage .......................................................................... 438 b) Sulprostone in Pregnancy Termination............................................................................... 439

3. PG E2 Misoprostol .................................................................................................................. 441 a) Misprostol General Aspects................................................................................................ 441 b) Misoprostol in Prolonged Pregnancy.................................................................................. 442 c) Misoprostal in Induced Abortion ........................................................................................ 444 d) Misoprostol for Post Partum Hemorrhage .......................................................................... 445 e) Misoprostol Ulcer protection .............................................................................................. 447

B. Prostaglandin Complications ............................................................................................................ 449 1. Prostaglandin E2 induced Cardiac Arrest ................................................................................ 449 2. PGE2 induced Uterine Rupture and Death .............................................................................. 450

IV. SURGICAL MANAGEMENT OF VARICEAL BLEEDS ..................................................................... 451 A. Transjugular Intrahepatic Portosystemic Shunt (TIPS)...................................................................... 451

1. TIPS General Aspects.............................................................................................................. 451 2. TIPS after Failure of Sclerotherapy ......................................................................................... 454 3. TIPS for Recurrent Bleeding ................................................................................................... 457 4. TIPS for Emergency Surgery of Active Variceal Bleeding ..................................................... 459

V. VOLUME EXPANDERS............................................................................................................................. 461 1. General Aspects of Volume Replacement Solutions ............................................................... 461

a) Expanders General Aspects ................................................................................................ 461 b) Expanders and Effect on Neutrophil Activation................................................................. 463 c) Expanders effect on Coagulation ........................................................................................ 463

2. Colloids and immune function................................................................................................. 468 3. Fluid Resuscitation (FR).......................................................................................................... 468

a) FR for Children Risks of Hypotonic Fluids ........................................................................ 468 b) FR in Children with Burn injury......................................................................................... 469

A. RINGERS SOLUTION (RS)............................................................................................................... 470 1. RS general Aspects .................................................................................................................. 470 2. Ringers Lactate Solution ........................................................................................................ 471 3. Ringers Acetate Solution........................................................................................................ 472 4. Ringers Bicarbonate Solution................................................................................................. 473

B. Hypertonic Saline Infusions .................................................................................................................. 475 A. HS Function and Use........................................................................................................................ 475

1. Hypertonic Saline general Aspects .......................................................................................... 475 2. HS fluid Resuscitation ............................................................................................................. 475 3. Hypertonic saline for Hemorrhagic Shock .............................................................................. 477

a) HS effects in general for Hemorrhagic shock..................................................................... 477 b) Low Volume HSR in Hemorrhagic Shock ......................................................................... 478 c) HSR effect on Heart and Ischemia...................................................................................... 478 d) HSR Effect on Lung injury in Hemorrhagic Shock............................................................ 480

4. HS for Thermal Injuries........................................................................................................... 482 5. HS for Trauma ......................................................................................................................... 482 6. HS for CNS-Injuries ................................................................................................................ 482

a) HS in Intracranial Pressure ................................................................................................. 482 b) HS for Stroke...................................................................................................................... 483 c) HS for Head Trauma........................................................................................................... 484

1) HS for Head Trauma of Adults ...................................................................................... 484


2) HS in Head Trauma of Children .................................................................................... 484 7. HS for Spinal Injuries ............................................................................................................. 485 8. HS Immunomodulatory effects................................................................................................ 485

B. HS or HSD Complications ............................................................................................................... 486 1. HS Complications Rebleeding in uncontrolled Hemorrhage!. ................................................ 486 2. HS induced Rebound Malignant Edema.................................................................................. 486

C. Polygeline (Haemaccel) ........................................................................................................................ 486 A. Function and Use.............................................................................................................................. 486

1. Polygeline General aspects ...................................................................................................... 487 2. Polygeline Solutions in Cardiac Surgery ................................................................................. 487 3. Polygeline for Spinal Anesthesia induced Hypotonia.............................................................. 490 4. Polygeline effects on Coagulation ........................................................................................... 491 5. Polygeline in Trauma............................................................................................................... 493 6. Polygeline in Organ preservation ............................................................................................ 495 7. Polygeliine in Partial Exchange Transfusion (PET) ................................................................ 495

B. Polygeline Complications................................................................................................................. 496 1. Polygeline induced Allergy and Anaphylactoid Reactions...................................................... 496 2. Polygeline Induced Effects on Cardiac Function..................................................................... 498 3. Polygeline induced Coagulopathy ........................................................................................... 498 4. Polygeline infusion and Air Embolism.................................................................................... 498

D. Hydroxyethyl-Starch (Hetastarch) ........................................................................................................ 499 A. Function and Use.............................................................................................................................. 499

1. HES General Aspects .............................................................................................................. 499 2. HES in Cardiac Surgery........................................................................................................... 503 3. HES in Resuscitation ............................................................................................................... 504 4. HES in Renal Transplantation ................................................................................................. 504 5. HES in Urologic surgery ......................................................................................................... 504 6. HES in Trauma ........................................................................................................................ 505 7.HES effect on Coagulation ....................................................................................................... 505

B. HES Complications .......................................................................................................................... 510 1. HES induced Renal Failure ..................................................................................................... 510 2. HES induced Coagulopathy..................................................................................................... 510

a) HES induced Coagulopathy General .................................................................................. 510 b) HES Induced Type I von Willebrandt Syndrome............................................................... 511 c) HES effect on Platelet Function.......................................................................................... 512

E. Dextran .................................................................................................................................................. 512 A. Function and Fields of Use............................................................................................................... 512

1. Dextran General Effects .......................................................................................................... 513 2. Dextran for Vascular Surgery as Thrombosis Prophylaxis...................................................... 513 3. Dextran for Prophylaxis of Deep Vein thrombosis in Orthopedic Surgery ............................. 514 4. Dextran for myocardial Reperfusion after Myocardial ischemia............................................. 515 5. Dextran for Acute Pulmonary Embolism ................................................................................ 516 6. Dextran Effect on Coagulation ................................................................................................ 516 7. Dextran Resuscitation for Shock with Hypertonic Saline Dextran.......................................... 520 8. Dextran for Prevention of intraperitoneal Adhesions .............................................................. 523 9. Dextran for Isovolemic Hemodilution..................................................................................... 524 10. Dextran for Dural Puncture Headache................................................................................... 524 11. Dextran for Endotoxin Shock ................................................................................................ 524 12. Dextran for Thermal Injury ................................................................................................... 526 13. Dextran 40 for Hypotension after Spinal Anesthesia............................................................. 527

B. Dextran induced Complications ....................................................................................................... 528 1. Prophylactic Treatment of Dextran Induced Anaphylactic Reactions ..................................... 528

a) Hapten Inhibition ................................................................................................................ 528 2. Methylprednisolone for Dextran induced Arthralgia Myalgia Syndrome ............................... 530

F. Albumin ................................................................................................................................................. 531 A. Function and Use.............................................................................................................................. 531

1. Albumin General Aspects and Use of it. ................................................................................. 531 2. Albumin increases Insulin-like Growth Factor -1.................................................................... 536 3. Albumin level in Anemia......................................................................................................... 537 4. Albumin in the Neonatal care .................................................................................................. 538


5. Albumin in Thermal Injury...................................................................................................... 539 6. Albumin for Hypoalbuminemia............................................................................................... 541 7. Albumin in Nephrotic Syndrome............................................................................................. 542 8. Albumin in Sepsis.................................................................................................................... 542 9. Albumin in Cirrhotic patients with Peritonitis reduce Renal impairment................................ 543 10. Albumin in Hemorrhagic Shock " NO!"................................................................................ 544 11. Albumin in Hyperbillirubinemia ........................................................................................... 546 12. Albumin in End Stage Liver Disease "To Substitute or not"................................................. 547 13. Albumin in Critical illness..................................................................................................... 549

B. Albumin Adverse Effects ................................................................................................................. 549 1. Albumin induced Metabolic Acidosis ..................................................................................... 549 2. Albumin induced Cardiac Dysfunction ................................................................................... 549

G. IntraVenous Immunoglobulins............................................................................................................... 550 "IVIG -Therapy".......................................................................................................................................... 550

A. IVIG General Aspects and Use ........................................................................................................ 550 1. IVIG General Aspects.............................................................................................................. 550

a) IVIG Effect on Complement............................................................................................... 550 b) IVIG Immunomodulation ................................................................................................... 551 c) IVIG Neutralizing Antibodies to ........................................................................................ 551 d) IVIG Effect on Neutrophil Function................................................................................... 552

2. IVIG in Trauma Patients.......................................................................................................... 553 3. IVIG in Immune Thrombocytopenic Purpura.......................................................................... 553 4. IVIG and AITP ........................................................................................................................ 558 5. IVIG and Prenatal Treatment................................................................................................... 559 6. IVIG in Antiphospholipid Syndrome ...................................................................................... 560 7. IVIG for Newborn Icterus ....................................................................................................... 561 8. IVIG for Immunologic Abortion ............................................................................................. 562 9. IVIG in Kawasaki Disease....................................................................................................... 563 10. IVIG for Neonatal Autoimmune Hemolytic Anemia ............................................................ 564 11. IVIG in Neurologic Diseases................................................................................................. 564

a) IVIG in Guillan-Barre Syndrome ....................................................................................... 564 b) IVIG in Multiple Sclerosis ................................................................................................. 566 c) IVIG For Stiff-Man Syndrome ........................................................................................... 567

12. IVIG in Autoimmune Muscular Diseases.............................................................................. 567 13. IVIG for Streptococcal Toxic Shock Syndrome .................................................................... 568 14. IVIG for Acquired Hemophilia with High-Titrer Inhibitor ................................................... 569 15. IVIG for LVAD Patients waiting for Heart Transplantation ................................................. 569

B. IVIG Complications ......................................................................................................................... 570 1. IVIG Neurologic Complications.............................................................................................. 570 2. IVIG Induced Neutropenia ...................................................................................................... 571 3. IVIG induced Renal Failure..................................................................................................... 571 4. IVIG induced Pleural Effusions............................................................................................... 573 5. IVIG induced Thrombosis ....................................................................................................... 573 6. IVIG induced Myocardial Infarction ....................................................................................... 573

H. Mannitol (MAN) ...................................................................................................................................... 574 A. MAN Function and Use ................................................................................................................... 574

1. MAN Reperfusion Injury......................................................................................................... 574 2. MAN in Crush Syndrome and Rhabdomyolysis ..................................................................... 577 3. MAN in Neuroprotection......................................................................................................... 578

a) MAN and Neuromonitoring................................................................................................ 578 b) MAN for Cerebral Edema after Stroke............................................................................... 581

4. MAN in Head Trauma ............................................................................................................. 585 a) MAN for Intracerebral Hypertension.................................................................................. 585 b) Man for Pediatric Head Trauma ......................................................................................... 595 c) MAN for Transtentorial Herniation .................................................................................... 596

5. MAN in Cohlear Dysfunction ................................................................................................. 597 6. MAN and Renal effects ........................................................................................................... 597

a) Mannitol and Furosemide in Nephrotic Syndrome............................................................. 597 b) Mannitol effect on Kidneys after Surgery .......................................................................... 597 c) Mannitol in acute Renal failure........................................................................................... 598


7. MAN for Urologic Surgery ..................................................................................................... 599 8. MAN for Water Intoxication ................................................................................................... 600 9. MAN for Acute Hyponatremia ................................................................................................ 601

B. MAN Complications ........................................................................................................................ 601 1. MAN induced Renal Failure, Nephrotoxicity.......................................................................... 601 2. MAN induced Shock, intracranial Hypertension..................................................................... 603


INTRAOPERATIVE TREATMENT I. HEMOSTATIC AGENTS

A. Collagen in Surgery and Hemostasis

1. Collagen for Testing Platelet Aggregation

(1) Kabakibi A, Vamvakas EC, et al . COLLAGEN-INDUCED WHOLE BLOOD PLATELET AGGREGATION IN PATIENTS UNDERGOING SURGICAL PROCEDURES ASSOCIATED WITH MINIMAL TO MODERATE BLOOD LOSS. Am J Clin Pathol 1998 Apr;109(4):392-398

Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston 02114, USA. Intraoperative bleeding due to platelet disorders is a persistent problem. Therefore, a screening assay to identify patients who are likely to bleed as a result of platelet dysfunction would be useful in formulating decisions about patient care. A previous study indicated that preoperative collagen-induced whole blood platelet aggregation predicts bleeding in patients undergoing surgery with cardiopulmonary bypass, a procedure associated with substantial blood loss. In the current study, we assessed the ability of the same whole blood platelet aggregation test to predict blood loss in patients undergoing surgical procedures not associated with substantial blood loss. The study included 369 adult patients (165 men and 204 women). Patients with excessive blood loss (defined as blood loss at or above the 75th or 90th percentile of the estimated blood loss values of patients undergoing procedures of similar invasiveness) had similar platelet aggregation values as patients who did not experience excessive blood loss. Thus, for patients undergoing operations not associated with substantial blood loss, the results of preoperative collagen-induced whole blood platelet aggregation are not effective in identifying patients likely to experience excessive blood loss.

2. Collagen Hemostat in Auto,transfusion use of Leukocytefilters Pall RC100

(1) Orr MD, Ferdman AG, Maresh JG REMOVAL OF AVITENE MICROFIBRILLAR COLLAGEN HEMOSTAT BY USE OF SUITABLE TRANSFUSION FILTERS. Ann Thorac Surg 1994 Apr;57(4):1007-11

Department of Anesthesiology, University of Texas Health Science Center, San Antonio. We assessed the ability of two commercial filters (Pall RC100 and Statlabs 20 microns) to filter out Avitene microfibrillar collagen hemostat from suspension. Quantitative determination of the collagen content as well as scanning electron and light microscopy, particle counting, and platelet aggregometry of filtrates revealed that these filters effectively remove potentially thrombogenic particles of Avitene microfibrillar collagen hemostat. The filters removed at least 97% of the total collagen, as determined by hydroxyproline analysis. The collagen that passed through the Pall filter did not pellet upon ultracentrifugation. Scanning electron and light microscopic analysis revealed no Avitene microfibrillar collagen hemostat particulates in the Pall filtrates but did reveal the presence of a significant number of approximately 1- to 8-microns particulates in the Statlabs filtrates. Concentrates of the filtrates from either of the two filters, however, did not promote platelet aggregation. Through ultracentrifugation and infrared analysis, the filtrates were found to consists of soluble, partially denatured collagen. The risk associated with the reintroduction of collagen particulates into the vasculature can be significantly reduced by use of appropriate, currently available blood-transfusion filters.


(2) Silber S HEMOSTASIS SUCCESS RATES AND LOCAL COMPLICATIONS WITH COLLAGEN AFTER FEMORAL ACCESS FOR CARDIAC CATHETERIZATION: ANALYSIS OF 6007 PUBLISHED PATIENTS. Am Heart J 1998 Jan;135(1):152-156

Dr. Muller Hospital, Munich, Germany. Since the first clinical studies regarding sealing of arterial puncture sites with collagen with the use of the vascular hemostatic device (VHD) and the hemostatic puncture closing device (HPCD) in the early 1990s were performed, no analysis summarizing the published patients has been reported. Therefore we performed a Medline search of data as far back as 1990 and included abstracts presented at the major scientific meetings in the United States (American Heart Association, American College of Cardiology), Europe (European Society of Cardiology), and Germany (German Society of Cardiology). A total of 6007 patients were found to have been enrolled in studies with VHD (4448 patients) or with HPCD (1559 patients). Parameters analyzed in this review were hemostasis success rates and local complications. To assess the impact of the sealing device

blood conservation techniques and perioperative planning part 3 · 2008. 10. 15. · k.r part 3 of...

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