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.

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.

Background: There are studies to prove the role of amylase and lipase estimation as a screening diagnostic tool to detect diseases apart from acute pancreatitis. However, there is sparse literature on the role of serum and urine amylase, lipase levels, etc to help predict the specific intra-abdominal injury after blunt trauma abdomen (BTA). Aim: To elucidate the significance of elevation in the levels of amylase and lipase in serum and urine samples as reliable parameters for accurate diagnosis and management of blunt trauma to the abdomen. Materials and Methods: A prospective analysis was done on the trauma patients admitted in Jai Prakash Narayan Apex Trauma Center, AIIMS, with blunt abdomen trauma injuries over a period of six months. Blood and urine samples were collected on days 1, 3, and 5 of admission for the estimation of amylase and lipase, liver function tests, serum bicarbonates, urine routine microscopy for red blood cells, and complete hemogram. Clinical details such as time elapsed from injury to admission, type of injury, trauma score, and hypotension were noted. Patients were divided into groups according to the single or multiple organs injured and according to their hospital outcome (dead/discharged). Wilcoxon's Rank sum or Kruskal-Wallis tests were used to compare median values in two/three groups. Data analysis was performed using STATA 11.0 statistical software. Results: A total of 55 patients with median age 26 (range, 6-80) years, were enrolled in the study. Of these, 80% were males. Surgery was required for 20% of the patients. Out of 55 patients, 42 had isolated single organ injury [liver or spleen or gastrointestinal tract (GIT) or kidney]. Patients with pancreatic injury were excluded. In patients who suffered liver injuries, urine lipase levels on day 1, urine lipase/amylase ratio along with aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) on days 1, 3, and 5, were found to be significant. Day 1 serum amylase, AST, ALT, hemoglobin, and hematocrit levels were found significant in patients who had spleen injury. Serum amylase levels on day 5 and ALP on day 3 were significant in patients who had GIT injury. Urine amylase levels on day 5 were found to be statistically significant in patients who had kidney injury. In patients with isolated organ injury to the liver or spleen, the levels of urine amylase were elevated on day 1 and gradually decreased on days 3 and 5, whereas in patients with injury to GIT, the urine amylase levels were observed to gradually increase on days 3 and 5. Conclusion: Although amylase and lipase levels in the serum and urine are not cost-effective clinical tools for routine diagnosis of extra-pancreatic abdominal injuries in BTA, but when coupled with other laboratory tests such as liver enzymes, they may be significant in predicting specific intra-abdominal injury.

Background: Thromboelastography (TEG) is relatively recent assay to analyze the coagulation state of a blood sample, providing a continuous visualization of physical changes occurring during blood coagulation. There is a paucity of published literature on assessment of coagulation status using TEG in Indian population. Aim: The primary aim of the following study is to establish normal reference values for TEG in North Indian healthy volunteers and secondary aim is to compare them with conventional plasma-based routine coagulation tests and the manufacturers reference range. Materials and Methods: A total of 200 healthy volunteers comprised of 100 males and 100 females of age groups between 20 and 50 years, were enrolled over a period of 1 year, i.e., 2011-2012. Thromboelastometry (TEM) was performed on TEM-A automated thromboelastometer (Framar Biomedica, Rome, Italy), using whole blood non-additive (360 µl). TEG parameters analyzed were r-time, k-time, α-angle, maximal amplitude (MA). Prothrombin time (PT), activated partial thromboplastin time (aPTT) and platelet count was performed for all volunteers. The 95% reference range was calculated as (mean-1.96 standard deviation [SD]) to (mean + 1.96 SD). Results: Our reference values for 95% of 200 volunteers were r-time: 1.8-14.2 min, k-time: 0.7-7.3 min, α-angle: 27.3-72.3° and MA: 32.1-87.9 mm. Maximum clot strength was higher in women compared with men, however statistically insignificant. Overall 14.5% (29/200) of the volunteers had at least one abnormal parameter while 74% (149/200) had deranged TEG values using the manufacturer's reference range. Statistically significant variation was seen in r-time for 84.8% (P < 0.001), for k-time, in 87.1% (P < 0.001), for α-angle in 83.7% (P < 0.001) and for MA in 84% (P < 0.001), between the manufacturer and our reference range. Conclusion: The efficacy of classical coagulation test has been well-established; on the contrary TEG is a fairly recent assay and its utility for patient management remains to be demonstrated. We observed TEG to be oversensitive in determining coagulopathy where there is no clinical presentation. The manufacturer's reference values may not be appropriate for different ethnicity. TEG may give an overall representation of hemostasis; however, it cannot replace the conventional coagulation tests. We recommend the determination of normal TEG values by each laboratory for their target population.