No abstract

SummaryGoal-directed coagulation therapy is essential in the management of trauma patients with severe bleeding. Due to the complex nature of coagulation disorders in trauma, a quick and reliable diagnostic tool is essential. We report a severely injured multiple trauma patient who received haemostatic therapy with coagulation factor concentrates, guided by rotational thromboelastometry (ROTEM Ò ). Initial therapy consisted of fibrinogen concentrate (Haemocomplettan Ò P), as maximum clot firmness in the ROTEM analyses was low, whereas clotting time was normal. Later on, prothrombin complex concentrate was given to optimise thrombin generation. This approach enabled extended emergency hemihepatectomy to be performed without using fresh frozen plasma. As the EXTEM maximum clot firmness showed good clot quality, no platelets were transfused despite low platelet counts. This case shows the potential success of treatment using both fibrinogen concentrate and prothrombin complex concentrate, not only in restoring haemostasis but also in minimising requirement for transfusion of allogeneic blood products. Coagulopathy is a major challenge in trauma centres worldwide, and uncontrolled bleeding causes around 40% of all trauma-related deaths [1]. Coagulopathy is the likely cause if bleeding continues after a patient has received optimal acute surgical treatment and, if required, mechanical support to close a wound.Accurate and timely measurement of haemostatic potential is clearly needed to optimise the management of coagulopathy. Routine laboratory tests such as prothrombin time (PT) and activated partial thromboplastin time (aPTT) are widely used, although they have not been developed to guide coagulation therapy. The PT and aPTT are too slow to provide prompt results, while pathologic values in these tests are rarely associated with acute, clinically relevant bleeding. In contrast, thromboelastometry ⁄ thromboelastography support an accurate and timely assessment, not only of coagulation initiation but also the clot formation process and clot stability. A set of reagents helps evaluate different aspects of coagulation, including the stability and amplitude of the fibrin-based clot (thromboelastometric FIBTEM test). Increasingly, point-of-care methods (thrombelastography or thromboelastometry) are recognised as offering more rapid diagnosis of coagulopathy than laboratory tests [2][3][4]. Since 2001, thromboelastometry (ROTEM Ò , Pentapharm, Munich, Germany) has been used in our department as a point-of-care monitoring tool. It plays an essential role in our strategy to avoid or reverse coagulopathy in polytrauma patients.Large amounts of fresh frozen plasma (FFP) are part of treatment protocols in most trauma centres, although the efficacy of this treatment is questionable [5]. At the same time, transfusion has been associated with increased morbidity and mortality [6,7]. The risks associated with FFP include transfusion-related lung injury (TRALI), pathogen transmission [8,9] and immunosupression [10].

In older adults high intakes of ascorbic acid have modest effects on lowering high systolic blood pressure, which could contribute to the reported association between higher vitamin C intake and lower risk of cardiovascular disease and stroke.

The vascular effects of dietary vitamin E were investigated in isolated carotid artery preparations from cholesterol-fed New Zealand White rabbits. Rabbits were fed either a control, 1% cholesterol, or 1% cholesterol plus 0.2% vitamin E diet for 4 weeks. In raised-tone preparations, relaxant responses to acetylcholine were enhanced in rabbits fed cholesterol plus vitamin E, reversing the reduction in responses measured in preparations from cholesterol-fed rabbits. Relaxant responses to the calcium ionophore A23187 were significantly enhanced in cholesterol plus vitamin E-fed rabbits compared with those fed cholesterol alone, with no difference between control and cholesterol-fed rabbits. Relaxant responses to sodium nitroprusside were not different between the three dietary groups. Constrictor responses to noradrenaline and serotonin in isolated carotid artery preparations at basal tone were unaltered after cholesterol and cholesterol plus vitamin E diets. The copper-induced oxidation of beta-very-low-density lipoproteins (beta VLDL) isolated from plasma of rabbits fed a cholesterol plus vitamin E diet was almost completely inhibited compared with the oxidation of beta VLDL from rabbits fed cholesterol alone. These results show that vitamin E prevents endothelial dysfunction associated with cholesterol feeding and suggests that vitamin E may be beneficial in preventing functional impairment associated with atherosclerosis.