Context: Over ordering of blood is a common practice in elective surgical practice. Considerable time and effort is spent on cross-matching for each patient undergoing a surgical procedure. Aims: The aim of this study was to compile and review the blood utilization for two key departments (Neurosurgery and Surgery) in a level 1 trauma center. A secondary objective was to formulate a rational blood ordering practice for elective procedures for these departments. Materials and Methods: Analysis of prospectively compiled blood bank records of the patients undergoing elective surgical, neurosurgical procedures was carried out between April 2007 and March 2009. Indices such as the cross-matched/transfused ratio (C/T ratio), transfusion index and transfusion probability were calculated. The number of red cell units required for each procedure was calculated using the equation proposed by Nuttall et al, using preoperative hemoglobin and postoperative hemoglobin for each elective surgical procedure. Results: There were 252 surgery patients (age range: 2-80 years) in the study. One thousand and eighty-eight units of blood were cross-matched, 432 were transfused (CT ratio 2.5). 44.0% patients did not require transfusion during entire hospital stay. Three (50%) elective procedures had CT ratio >2.5and 4 (66.6%) elective procedures had TI 2.5, with five of them exceeding 4. In procedures like spinal instrumentation the CT ratio was <2.5 and 10 (90.9%) of elective procedures had TI <0.5. Conclusions: In this study 40% and 22% of cross-matched blood was being utilized for elective general surgery and neurosurgical procedures, respectively. The calculated required blood units for all elective Trauma surgery procedures were more than 2 units. The calculated required blood units were less than 0.5 units in four of the 11 neurosurgical procedures, and hence only one unit should be arranged for them. It is crucial for every institutional blood bank to formulate a blood ordering schedule. Regular auditing and periodic feedbacks are also vital to improve the blood utilization practices.

Objective/background: Early coagulopathy in isolated severe traumatic brain injury occurs despite the lack of severe bleeding, shock, and fluid administration. We aimed to correlate coagulation activation/inhibition, thrombin generation and fibrinolysis with the development of acute trauma induced coagulopathy (TIC) and its effects on early mortality in isolated severe traumatic brain injury (iSTBI) patients. Methods: A prospective screening of iSTBI patients was done for two years. History of anticoagulants, liver disease, hypotension, extracranial injuries, transfusion, brain death were excluded. TIC was defined as international normalized ratio (INR) ≥ 1.27 and/or prothrombin time (PT) ≥ 16.7 seconds and/or activated partial thromboplastin Time (aPTT) ≥ 28.8 seconds on admission following iSTBI. Analysis of tissue factor (TF), tissue factor pathway inhibitor (TFPI), protein C (PC), protein S (PS), thrombin/antithrombin complex (TAT), soluble fibrin monomer (sFM), tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) was done. Cases were categorized as presence or absence of TIC and 20 healthy controls participants were included. Results: A total of 120 cases met the inclusion criteria, aged 35.7 ± 12.12 years, 96% males. TIC was identified in 50 (41.6%). TIC occurred independently of age, sex, Glasgow coma scale (GCS) but was associated with acidosis (60%; p = .01). Following iSTBI significant decline was seen in coagulation activation. Thrombin generation and fibrinolysis were markedly increased. TF, TFPI, PC and PS were low in TIC compared with control. Significant depletion of PS was seen in TIC versus No-TIC. TBI patients with depleted PS had an odds ratio (OR) of 7.10 (1.61–31.2) for TIC. Receiver operating characteristic curve (ROC) analysis depicted area under the curve (AUC) of 0.73 (95% confidence interval [CI] 0.63–0.84) with a cut-off of ≥74 of PS (specificity 63.9%, sensitivity 72.7%). In-hospital mortality was higher in TIC group (44%) compared with no-TIC (20%) with OR of 4.73 (95% CI 1.68–13.3) and hazard ratio [HR] of 2.8 (95 % CI 1.2–6.4). Conclusion: Incidence of TIC in iSTBI is 41.6%, with 4.7 times odds for mortality. Traumatic brain injury causes enhanced coagulation activation, inadequate inhibition, exacerbation of thrombin generation, and subsequent increased fibrinolysis. ROC curve analysis revealed a cut-off of PS ≤ 74 with specificity 63.8%, sensitivity 72.7% for development of TIC.

Traumatic brain injury (TBI) causes activation of several neurochemical and physiological cascades, leading to neurological impairment. We aimed to investigate the level of novel chemokine RANTES in plasma, cerebrospinal fluid (CSF) and contused brain tissue in traumatic brain injury patients and to correlate the expression of this chemokine with the severity of head injury and neurological outcome. This longitudinal case control study was performed on 70 TBI patients over a period of 30 months. Glasgow coma scale (GCS) and Glasgow outcome score were used to assess the severity of head injury and clinical outcome. Level of RANTES was quantified in plasma (n = 60), CSF (N = 10) and contused brain tissue (n = 5). Alterations in the plasma levels on 1st and 5th day following TBI were assessed. Patients were categorized as severe (GCS < 8) (SHI), moderate and mild Head injury (GCS > 8–14). 15 healthy volunteers were taken as the control group. The median plasma RANTES levels were 971.3 (88.40–1931.1); 999.2 (31.2–2054.9); 471.8 (370.9–631.9) for SHI, MHI and healthy control respectively and showed statistically significant variation (p = 0.005). There was no statistical difference in the mean 1st and 5th day RANTES levels for the SHI group. However, admission RANTES levels were significantly higher in patients who died than those who survived (p = 0.04). Also, RANTES levels were significantly higher in plasma as compared to contused brain tissue and CSF (p = 0.0001). This is the first study of its kind which shows that there is significant correlation of admission RANTES levels and early mortality. Another interesting finding was the significant upregulated in the expression of RANTES in plasma, compared to CSF and contused brain tissue following severe TBI.

Toll-like receptor 3 (TLR3) is a pathogen recognition molecule associated with viral infection with double-stranded RNA (dsRNA) as its ligand. We evaluated the role of TLR3 in bacterial pneumonia using Klebsiella pneumoniae ( KP ). WT and TLR3 ^–/– mice were subjected to a lethal model of KP . Alveolar macrophage polarization, bactericidal activity, and phagocytic capacity were compared. RNA-sequencing was performed on alveolar macrophages from the WT and TLR3 ^–/– mice. Adoptive transfers of alveolar macrophages from TLR3 ^–/– mice to WT mice with KP were evaluated for survival. Expression of TLR3 in postmortem human lung samples from patients who died from gram-negative pneumonia and pathological grading of pneumonitis was determined. Mortality was significantly lower in TLR3 ^–/– , and survival improved in WT mice following antibody neutralization of TLR3 and with TLR3/dsRNA complex inhibitor. Alveolar macrophages from TLR3 ^–/– mice demonstrated increased bactericidal and phagocytic capacity. RNA-sequencing showed an increased production of chemokines in TLR3 ^–/– mice. Adoptive transfer of alveolar macrophages from the TLR3 ^–/– mice restored the survival in WT mice. Human lung samples demonstrated a good correlation between the grade of pneumonitis and TLR3 expression. These data represent a paradigm shift in understanding the mechanistic role of TLR3 in bacterial pneumonia.

Aim: The aim of our study was to do an agreement analysis of two different laboratory methods used to measure electrolytes i.e., between the ISE based Beckman Coulter Synchron CX9 PRO Biochemistry analyzer and RAL′s Ion3 Flame Photometer (Técnica para el Laboratorio, Barcelona, Spain), in serum samples. Materials and Methods: This cross sectional study was done over a period of three months from September′09 through December′09 on routine biochemistry samples. A total of 6492 samples were received for routine biochemistry analysis from those 630 blood samples were randomly processed for this study. Two ml of sample was taken in a plain gel tube (LABTECH Disposables, Ahmedabad, India), centrifuged and further processed using both systems within one hour of the sampling to obtain the Na and K concentrations in the samples. The bias and variability of differences in measured values were analyzed according to Bland and Altman method. Results: Flame photometry method has drawbacks such as low throughput, requires manual operation, is a time consuming procedure. Ion selective electrodes technique is a more universal method for the high throughput determination of electrolytes in physiological samples; Beckman Coulter Synchron CX9 PRO is an example of such a system. The mean difference between the two methods (standard minus test) and 95% limits of agreement for sodium in serum was -7.8±17.3 (-42.2 to 26.6) and in urine was -22±41 (-104 to 60). Similarly, the mean difference between the two methods for potassium values in serum was found to be -0.25±0.75 (-1.75 to 1.25) and in urine was -5.3±38.9 (-83.1 to 72.5). With 95% confidence interval, the value of sodium and potassium as determined by both the methods lie between the upper and lower limit showing 95% limits of agreement. Conclusion: Good degree of agreement was seen on comparing the two methods for measuring the electrolytes; the use of Synchron CX9 in place of Flame photometer for electrolyte analysis in serum and urine is justified or use the two interchangeably.