Brian Castillo

Successful management of severe red blood cell alloimmunization in pregnancy with a combination of therapeutic plasma exchange, intravenous immune globulin, and intrauterine transfusion: RBC ALLOIMMUNIZATION IN PREGNANCY

Antibodies to Rhesus and Kell antigens have been associated with severe hemolytic disease of the fetus and newborn (HDFN) necessitating intrauterine transfusion (IUT) of red blood cells (RBCs). We report a case series of five women with severe HDFN secondary to maternal RBC alloimmunization who were successfully managed with therapeutic plasma exchange (TPE), intravenous immune globulin (IVIG), and IUT.

Intra-pericardial use of recombinant factor VIIa in a patient with acute hemorrhagic pericardial effusion following transcutaneous aortic valve replacement-a case report

Perioperative bleeding can be a serious life-threatening complication in adult patients undergoing cardiac surgery, given the older age and additional comorbidities present in this patient population. The standard treatment options include transfusion of blood components and surgical re-exploration. We report the first case of an elderly female patient treated with local administration of recombinant factor VIIa (rFVIIa) for intractable hemorrhagic pericardial effusion, which developed following a transcutaneous aortic valve replacement (TAVR) procedure for severe aortic stenosis. No thromboembolic phenomena or adverse effects were observed. Local administration of rFVIIa is an efficacious treatment option for cardiac surgery patients as opposed to systemic administration of rFVIIa, use of massive blood products, or surgical re-exploration.

Bleeding Related to Cardiac Surgery

Cardiac surgery has now been performed for over a hundred years. Research in the heart-lung machine by Dr. Gibbon made cardiopulmonary bypass (CPB) a reality, and advancements in the field in the 1950s and 1960s have made cardiac surgery what we know today. However, with these innovations came the realization of major bleeding complications in this subpopulation of patients, accounting for nearly 25 % of transfused products in the United States. The risk factors for bleeding in cardiac surgery patients manifest intraoperatively, primarily due to the effects of CPB, including hypothermia and hyperfibrinolysis, and secondarily due to massive transfusion and dilutional coagulopathy. Furthermore, some of these effects may persist into the immediate postoperative period. Additionally, there are also preoperative risk factors to consider such as medication effect (anticoagulants, antiplatelet medications), previous sternal surgeries, and history of liver disease and/or renal insufficiency. Management can include evaluation by a qualified physician for bleeding risk assessment to determine the severity of bleeding complications that may occur in the perioperative period and if appropriate delay surgery if the risks of bleeding outweigh the benefits. However, in many situations these patients are critical and require immediate surgery. In these cases, management of coagulopathy can include not only blood product support but also consideration of reversal of anticoagulation with appropriate reversal agents, management of massive transfusion, and, in cases of severe bleeding, consideration of hemostatic agents such as prothrombin complex concentrates and recombinant factor VIIa.

A Rare Case of Acquired Fanconi's Syndrome With Monoclonal Gammopathy in an Infant.

Monoclonal gammopathies associated with acquired Fanconis syndrome (AFS) have been reported in the adult population. AFS is characterized by renal dysfunction resulting in proteinuria, aminoaciduria, hypophosphatemia, glucosuria, and hyperchloremic metabolic acidosis. In this case report, we document the clinical and laboratory findings of a preterm infant with features of both AFS and monoclonal gammopathy in the urine.