Efficacy of Bakri Balloon Tamponade in Massive Postpartum Hemorrhage: A Series of 57 Cases

( Ha Yan Kwon ),( Young-han Kim ),( Yong-won Park ),( Ja-young Kwon ) 대한주산의학회 2016 大韓周産醫學會雜誌 Vol.27 No.4

Purpose: To evaluate the efficacy of intrauterine Bakri balloon tamponade as a management of massive postpartum hemorrhage (PPH). Methods: Retrospective study including women who underwent intrauterine Bakri balloon tamponade for massive PPH between April 2010 and July 2015 was conducted. Massive PPH was defined as estimated blood loss exceeding 1,500 mL. Bakri balloon was inserted into uterus if women had PPH despite medical treatment after vaginal delivery or cesarean section. The balloon was inflated with sterile saline and removed after 12-24 hours. Failure was defined as needing another procedure for hemorrhage control. Demographic, obstetric and specific factors in regard to the Bakri balloon use were recorded. The successful rate of hemostasis by Bakri balloon was evaluated. Results: Among 138 women with PPH managed Bakri balloon insertion, 57 patients were diagnosed with massive PPH. The most common cause of massive PPH was placenta previa without accreta (54.4%), uterine atony (33.3%), placenta previa with accreta (10.5%) and placenta accreta (1.8%). The mean estimated blood loss was 2279.0 mL (range, 1,500-6,500 mL). The rate of successful control of massive PPH after Bakri balloon placement was 82.5%. From the cases of 57 patients, 10 patients needed additional procedures; five required uterine artery embolization and five underwent cesarean hysterectomy. No short-term complications or maternal death were observed after Bakri balloon insertion. Conclusion: Bakri balloon tamponade is an effective, simple and quick approach in the treatment of massive PPH and it is useful as complementary management for earning time for another procedure.

췌장의 가성낭종 파열에 의한 하부 위장관 출혈 1예

장성종,김병수,부귀범,김동규,박찬국,김만우,김정용,박상헌 조선대학교 부설 의학연구소 2000 The Medical Journal of Chosun University Vol.25 No.1

Pancreatic pseudocysts usually develop as a complication of acute pancreatitis or repeated attacks of chronic pancreatitis. Pseudocysts may also develop as a result of traumatic injuries or neoplasms. An uncommon complication is massive hemorrhage inside the pancreatic pseudocyst. The exact mechanism of hemorrhage is unknown. Enzymatic digestion, pressure erosion from the cyst mass or a combination of these processes may play an important role. Gastrointestinal hemorrhage associated with a pancreatic pseudocyst can occur in 10 percent of cases. When hemorrhage occurs because of erosion into a blood vessel involved in the pseudocyst, surgery is indicated since the episodes of hemorrhage are often severe and may even be fatal. When there is colonic involvement, various complications may occur. The most dangerous one is spontaneous rupture into the colon, which requires immediate surgical treatment because of high incidence of fulminating sepsis or massive hemorrhage. We examined a sixty eight-year-old man complaining of hematochezia and dizziness, and reported that it was a case of massive lower gastrointestinal hemorrhage caused by pseudocyst of the pancreas ruptured into the colon associated with chronic pancreatitis. On operative findings, the peripancreatic fatty tissue had severe adhesions to transverse colon and tail portion of pancreas, where the pseudocyst had formed. A distal pancreatectomy, splenectomy and resection of transverse colon were performed. By microscopic examination, hemorrhagic necrosis and inflammatory change were observed in the pancreas specimen. The tail portion of pancreas had a 6×6 cm sized cystic mass and was proven to be a pseudocyst with no epithelial lining.

Prognostic Accuracy of Massive Transfusion, Critical Administration Threshold, and Resuscitation Intensity in Assessing Mortality in Traumatic Patients with Severe Hemorrhage: a Meta-Analysis

강우성,신인수,표정수,안소라,정승우,기영준,석준필,박찬용,이선도 대한의학회 2019 Journal of Korean medical science Vol.34 No.50

Background: The aim of this study was to assess the prognostic value of massive transfusion (MT), critical administration threshold (CAT), and resuscitation intensity (RI) for the mortality of trauma patients with severe hemorrhage. Methods: Seventeen relevant articles were obtained by searching the PubMed databases through February 15, 2019. The estimated mortality rates and injury severity scores were obtained through a meta-analysis. In addition, diagnostic test accuracy (DTA) reviews were conducted to obtain the sensitivity, specificity, diagnostic odds ratio, and the summary receiver operating characteristic curve. Results: At 24 hours, the estimated mortality rates were 0.194, 0.126, and 0.168 in assessments using MT, CAT, and RI, respectively. In addition, the pooled sensitivity of CAT (0.89; 95% confidence interval [CI], 0.82–0.94) was significantly higher than that of MT (0.63; 95% CI, 0.57–0.68) and RI (0.69; 95% CI, 0.63–0.75). Overall, the pooled specificity of MT and CAT was 0.82 (95% CI, 0.80–0.83) and 0.85 (95% CI, 0.83–0.88), respectively, while the pooled sensitivity was 0.49 (95% CI, 0.44–0.54) and 0.50 (95% CI, 0.38–0.62), respectively. Conclusion: CAT may be a more sensitive predictor for 24-hour mortality than other predictors. Furthermore, RI also appears to be a useful predictor for 24-hour mortality. Both MT and CAT showed high specificity for overall mortality.

Anesthetic review of emergency peripartum hysterectomy following vaginal and cesarean delivery: a retrospective study

이인호,손주형,신영철,변재훈,윤해조,지영석 대한마취통증의학회 2012 Korean Journal of Anesthesiology Vol.63 No.1

Background: The purpose of this study was to review incidence, indications, complications, and the anesthetic management of emergency obstetric hysterectomies. Methods: This was a retrospective study of the cases of emergency obstetric hysterectomies performed at the Woman's Hospital over a 3 year period between January 2008 and December 2010. The indication for surgery,anesthetic management, operating time, estimated blood loss, pre- and postoperative hemoglobin and hematocrit values, need for blood transfusion, and perioperative complications were obtained. Results: During the study period there were 46 emergency obstetric hysterectomies for 20147 deliveries, giving an incidence of 2.28/1000 deliveries. The number of emergency hysterectomies was significantly higher with the cesarean deliveries than with the vaginal deliveries. The most common indication for emergency obstetric hysterectomy was placenta accreta. Postoperatively, Dissemimated Intravascular Coagulation (DIC) was the most common complication. Conclusions: Abnormal placenta has been an main indication of emergency hysterectomy. Anesthesiologists should be eligible to aware of high risk of emergency hysterectomy and deal with massive hemorrhage. Background: The purpose of this study was to review incidence, indications, complications, and the anesthetic management of emergency obstetric hysterectomies. Methods: This was a retrospective study of the cases of emergency obstetric hysterectomies performed at the Woman's Hospital over a 3 year period between January 2008 and December 2010. The indication for surgery,anesthetic management, operating time, estimated blood loss, pre- and postoperative hemoglobin and hematocrit values, need for blood transfusion, and perioperative complications were obtained. Results: During the study period there were 46 emergency obstetric hysterectomies for 20147 deliveries, giving an incidence of 2.28/1000 deliveries. The number of emergency hysterectomies was significantly higher with the cesarean deliveries than with the vaginal deliveries. The most common indication for emergency obstetric hysterectomy was placenta accreta. Postoperatively, Dissemimated Intravascular Coagulation (DIC) was the most common complication. Conclusions: Abnormal placenta has been an main indication of emergency hysterectomy. Anesthesiologists should be eligible to aware of high risk of emergency hysterectomy and deal with massive hemorrhage.

Analysis of Massive Transfusion for Trauma Patients and Non-Trauma Patients in a Tertiary Hospital

김혜림,유동원,신경화,이현지,김형회 대한수혈학회 2016 大韓輸血學會誌 Vol.27 No.3

Background: Management of patients with massive hemorrhage often requires the massive blood transfusions. However, few studies have investigated the effects of massive transfusions on non-traumatic patients. Therefore, this study analyzed mortality and descriptive data for patients receiving massive transfusion, including non-trauma patients and trauma patients. Methods: We reviewed a retrospective audit of massive transfusions to investigate the major causes, patient characteristics, ratio of the blood components, and the mortality of massively transfused patients. The analysis was performed using electronic medical records collected from January 2010 to December 2013. Patients who had received a massive transfusion (≥10 units of RBCs within 24-hours) were categorized into trauma and non-trauma patients. We calculated the ratio of blood components and investigated the relationship between ratio and mortality. Descriptive statistics were used to characterize the patients and the indications. Results: A total of 532 massive transfusions were performed, including 187 trauma and 345 non-trauma patients. The overall mortality rate was 32.0%, encompassing 36.4% of the trauma patients and 29.6% of the non-trauma patients. The mortality in trauma patients was significantly reduced (P<0.001) within the first 48-hours compared with that in non-trauma patients, which was due to the high FFP: RBC ratio transfusion. The annual FFP: RBC ratio in trauma patients showed an increasing trend. Non-trauma patients showed no relationship between mortality and procedure indication/blood component ratio. Conclusion: We report clinical data pertaining to massive transfusions. Annual increasing FFP: RBC ratio in trauma patients was associated with a decreasing mortality. Non-trauma patients showed heterogeneous characteristics and a lower FFP: RBC ratio than trauma patients.

직장 유암종에 대한 내시경적 절제술 시행 후 12일째 발생한 대량 지연 출혈 1예

김소미,윤세영,최훈수,라성수,공재환 대한소화기내시경학회 2009 Clinical Endoscopy Vol.38 No.2

Endoscopic resection is currently accepted as a standard therapy for colon polyp because of its safety and efficiency. The indications for endoscopic resection have been expanded to treat mucosal colon cancer and submucosal tumor. The major complications of endoscopic resection are hemorrhage, perforation and post- polypectomy coagulation syndrome. Hemorrhage is the most common complication, and this can occur immediately following colonoscopic polypectomy or it can be delayed after completion of the procedure. Delayed hemorrhage usually occurs within 7 days and this can stop by itself or the hemorrhage can be controlled endoscopically in the majority of patients, with only the unusual and serious cases requiring transfusion, angiography and surgery. We experienced a case of delayed massive hemorrhage with hypotension that required transfusion 12 days after performing endoscopic resection for rectal carcinoid tumor. We report here on this case to provide a good example and to place emphasis on delayed massive hemorrhage after endoscopic resection. 내시경적 용종 절제술은 대장 용종의 표준 치료로 인정받고 있으며, 내시경 술기 및 기기의 발달로 내시경적 점막절제술 및 내시경적 점막하 박리술을 이용하여 점막에 국한된 조기 대장암 및 일부 점막하 종양의 치료로 발전하고 있다. 이와 같은 내시경적 절제술은 비교적 안전하며 삶의 질을 높일 수 있어 수술적 치료를 대체하고 있으나 출혈, 천공 및 용종 절제술 후 응고 증후군 등의 합병증이 발생할 수 있다. 내시경적 용종 절제술과 관련된 가장 흔한 합병증은 출혈로서 약 0.3∼6.1%에서 발생하며 시술 중에 발생하는 즉시 출혈과 시술 이후에 발생하는 지연 출혈로 나눌 수 있다. 지연 출혈의 경우 대부분 일주일 내에 소출혈의 양상을 보이게 된다. 저자들은 1.2 cm 크기의 직장 유암종을 내시경적 절제술로 제거한 후 조기 출혈 없이 퇴원하였으나, 시술 12일째 불안정한 활력 징후를 보이며 수혈 치료가 필요했던 대량 지연 출혈 1예를 경험하여 문헌 고찰과 함께 보고한다.

초기 치료로 유리체강내 조직플라스미노겐 활성제, C3F8 가스, 항혈관내피세포성장인자 주입술을 시행받은 대량망막하출혈 환자의 치료 후 임상 경과

한지윤(Ji Yun Han),김성우(Seong-Woo Kim),오재령(Jaeryung Oh) 대한검안학회 2017 Annals of optometry and contact lens Vol.16 No.2

Purpose: To evaluate the clinical outcomes of eyes with massive subretinal hemorrhage (SRH) initially treated with intravitreal injection of tissue plasminogen activator (tPA), perfluoropropane (C3F8) gas and anti- vascular endothelial growth factor (anti-VEGF) (triple therapy). Methods: Twenty one eyes of 21 patients with massive SRH followed up for ≥ 3 months after triple therapy were retrospectively reviewed. The final diagnosis of patients, efficacy and clinical outcomes of the triple therapy were investigated. Results: The final diagnosis of 21 eyes consisted of three disease. 13 eyes (61.9%) were polypoidal choroidal vasculopathy, 4 eyes (19.0%) were age-related macular degeneration, 2 eyes (9.5%) were retinal macroaneurysm and 2 eyes (9.5%) could not be confirmed the final diagnosis. The mean size of SRH was 4.5 (±1.5) disc diameter. The visual acuity was improved in 10 eyes (47.6%), remained stable in 10 eyes (47.6%) and decreased in 1 eye (4.8%). The size of SRH and final diagnosis had not significant relationship on visual acuity change. For 12 eyes followed up for ≥ 12 months after triple therapy, the mean logMAR best-corrected visual acuity significantly improved at 12 months (p=0.023, Wilcoxon signed rank test). Conclusions: The triple therapy of tPA, C3F8 gas and anti-VEGF could be a one of effective initial treatment modality in stabilization and maintenance of visual improvement for massive SRH.

단일 3차 의료기관에서 외상환자에 대한 대량수혈 프로토콜 적용 분석

김혜린,유동원,김혜림,신경화,이현지,장철훈,김형회 대한수혈학회 2018 大韓輸血學會誌 Vol.29 No.3

Background: Massive hemorrhage due to trauma is one of the major causes of death in trauma patients, and the quick supply of appropriate blood products is critical in order to reduce the mortality rate. We introduced a massive transfusion protocol (MTP) for safe and rapid transfusion of trauma patients. Using records collected since its adoption, we compared the characteristics of MTP applied group (MTP group) and MTP not applied group (non-MTP group) to determine whether there is an indicator for predicting patients to be treated with MTP. Methods: We retrospectively reviewed the electronic medical records and laboratory findings of patients who received massive transfusions in the trauma emergency room of a single tertiary hospital from February to August 2018. We analyzed various laboratory test results, the amount and ratio of the transfused blood products, and the time required for blood products to be released for the MTP group and the non-MTP group. Results: Of the 54 trauma patients who received massive transfusions, 31 were in the MTP group and 22 in the non-MTP group. There was no significant difference in initial vital signs (except blood pressure) and laboratory test results. Also there was no difference in the amount and ratio of blood products, but the time required for blood product release was shorter in the MTP group. Conclusion: There was no significant difference in clinical findings such as initial vital signs and laboratory test results between the MTP and non-MTP groups, but required blood products were prepared and released more quickly for the MTP group.

응급산후자궁절제술 후 재개복술을 시행하였던 10예의 임상분석

박찬은 ( Chan Eun Park ),성지은 ( Ji Eun Sung ),경민선 ( Min Sun Kyung ),조용 ( Yong Cho ),노의선 ( Eu Sun Ro ) 대한산부인과학회 2010 Obstetrics & Gynecology Science Vol.53 No.4

목적: 응급산후자궁절제술 후 대량수혈에도 지속적인 출혈과 불안정한 활력징후를 보여 추가적인 재개복술이 시행되었던 10예의 환자들에 대한 임상적 특성, 재개복술에서 출혈의 원인 및 처치, 수혈양, 합병증, 그리고 예후 등을 분석함으로서 재개복술의 안전성과 효과를 알아보기 위해 본 연구를 시행하였다. 연구 방법: 1995년 1월부터 2008년 12월까지 대량수혈과 산후응급자궁절제술 후에도 지속적인 출혈과 불안정한 활력징후를 보여 대량수혈과 재개복술이 시행되었던 10예의 환자들에서 임상적 상태, 출혈의 원인, 재개복술까지의 시간과 효과, 수혈양, 합병증, 그리고 예후 등을 후향적으로 분석하였다. 결과: 10예 모두에서 재개복술에서 출혈 부위가 확인되어 출혈혈관 결찰 및 삼출성 출혈부위 봉합술, 2예에서 추가적인 자궁밑 둥제거술이 시행되었다. 출혈은 재개복술 시 다양한 부위에서 그리고 한 곳 보다는 여러 곳에서 발견이 되었고 출혈 양상은 노출된 작은 동맥에서 혈액 분출, 또는 수술 부위에서 삼출성 출혈을 보였다. 8예에서는 성공적인 지혈로 활력징후의 안정을 보였고 정상적인 혈색소 수치와 혈액응고 검사 소견을 유지하는데 필요한 농축적혈구, 신선냉동혈장 양이 크게 감소하였고 문제없이 회복되었다. 나머지 2예에서는 재개복술 후 출혈이 감소하였으나 다음날 다시 악화되어 경피적 동맥색전술을 시행하였으나 계속된 출혈과 다장기손상으로 사망하였다. 이 2예는 타 병원에서 전원되었으며 응급실에서 인공심폐소생술과 기관지삽관술이 각각 시행되었던 예였다. 결론: 대량수혈과 응급산후자궁절제술 후에도 지속적인 출혈로 시행된 개복술에서 모두 출혈 부위가 확인되어 대부분 성공적으로 지혈되어 빠른 회복을 보였다. 응급산후자궁절제술에서 대량 출혈에 따른 혈압의 저하로 혈관의 수축이 일어나 있어서 작은 혈관에서의 출혈은 감지하기 어려우므로 혈압을 상승시킨 후 출혈 여부를 재확인하고 수술을 종료하는 방법도 재출혈의 예방에 도움이 될 것으로 사료 된다. 응급자궁절제술이 시행되었더라도 재출혈이 발생하고 활력징후가 불안정하여 진다면 재개복술 시행을 지체하지 않아야 하며 혈액응고 관련 인자를 충분히 투여함이 중요한 것으로 사료된다. Objective: To analysis the 10 cases of relaparotomy for intractable hemorrhage after emergency postpartum hysterectomy with massive transfusion. Methods: Between January 1995 and December 2008, relaparotomies for intractable hemorrhage and unstable vital sign after emergency postpartum hysterectomy with massive transfusion were performed on 10 patients. Medical records were reviewed and detailed to collect clinical data including patients` clinical status, causes of bleeding, duration from hysterectomy to relaparotomy, bleeding sites, procedures for bleeding control, amount of transfusions, complications and prognosis. Results: In relaparotomies, the points of bleeding were identified in all cases and multiple bleeding foci than one bleeding focus were found, and procedures for bleeding control were performed. In 8 cases, the bleeding were controlled successfully and these patients recovered without long term sequales. But in the other 2 cases, although the bleeding controls were successful during relaparotomy and bleeding amount decreased after relaparotomy, but bleeding amount increased the next day and angiographic embolizations were performed. These patients died due to multi-organ failure and continued bleeding. In one of these cases, the endotracheal intubation had been done on arrival at our hospital with postpartum hemorrhage after vaginal delivery at private clinic. In another case, the cardiopulmonary resuscitation was performed on arriving at our hospital with intractable bleeding after postpartum subtotal hysterectomy in other hospital. Conclusion: In most cases, bleeding controls for intractable bleeding after postpartum hysterectomy were successful during and after relaparotomy in spite of development of dilutional coagulopthy due to massive transfusion, and resulted in rapid recovery and good prognosis. Even though dilutional coagulopthy was developed because of massive transfusion, relaparotomy was safe and effective procedure for management of intractable hemorrhage after emergency postpartum hysterectomy with clotting factor replacement. If personnel and adequate clotting factor replacement are available, relaparotomy should not be delayed for management of intractable hemorrhage and unstable vital sign after emergency postpartum hysterectomy.

저에너지 외상에 의한 비전위 치골지 골절에서 발생한 대량출혈

나화엽,신근영,최세헌 대한정형외과학회 2019 대한정형외과학회지 Vol.54 No.6

Most low-energy pelvic ring fractures in elderly patients are treated conservatively so that an initial evaluation for complications such as vascular injury is usually overlooked. An 81-year-old female, who was taking regular aspirin, visited the emergency room and was diagnosed with a simple non-displaced pubic ramus fracture from a low-energy fall from standing, which was complicated by massive hemorrhage from the overlooked injury of the corona mortis. Elderly patients with pelvic ring fractures can have a delayed presentation of vascular injuries, regardless of the degree of displacement of the fractures, which highlights the need for a careful physical examination and close monitoring. 대부분의 저에너지 외상에 의한 골반환 골절은 합병증 없이 보존적 치료만으로 호전이 되어 혈관손상 등의 합병증에 대한 초기평가를 간과하기 쉽다. 본 증례보고에서는 평소 aspirin을 복용하던 81세 여자환자가 낙상으로 비전위성 치골지 골절이 발생하면서 corona mortis가 손상되어 나타난 대량출혈을 보고하는 바이다. 고령의 골반환 골절 환자에서는 골절의 전위 여부와 관계없이 혈관손상이 지연되어 발생할 수도 있기 때문에 면밀한 이학적 검사 및 감시가 필요하다