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Monday, 2 December 2013

Hemorrhaging: Pulmonary hemorrhage (P-Hem) - The Complications and Treatments

Hemorrhaging is also known as bleeding or abnormal bleeding as a result of blood loss due to internal.external leaking from blood vessels or through the skin.
Pulmonary hemorrhage (P-Hem)
Pulmonary hemorrhage is defined  as a acute condition of lung bleeding from the from the upper respiratory tract or the endotracheal tube of the lung with the mortality of 30 to 40%.
Complication
1. Leptospirosis
 Leptospirosis is a widespread zooanthroponosis that is prevalent in tropical regions due to the
favorable environmental survival conditions of its etiologic agent (Leptospira)(12).

2. Fetomaternal complications
Antenatal diagnosis and treatment of women with hereditary hemorrhagic telangectasia and pulmonary arteriovenous malformations might prevent potentially lifethreatening fetomaternal complications(13).

3. Pulmonary infection and respiratory failure
 In the study of spinal cord injury (SCI) rats, pulmonary edema and hemorrhage were occurred in the early stage of SCI while the other organs were almost normal. And the location of lung edema and hemorrhage were the same as that of pulmonary infection(14).

4. Etc.


E.4. Treatments 
Treatments depend on the diagnosis of each patient, if the underlined cause is due to medication, then medicine has to be stopped.

1. Immediate treatment
According to the Intensive Care Nursery House Staff Manual immediate treatment of P-Hem should include tracheal suction, oxygen and positive pressure ventilation. To assist in decreasing P-Hem, mean
airway pressure should be increased, either by a relatively high PEEP (i.e., 6 to 10
cmH2O) or by high frequency ventilation(15). In the infants, reserachers at suggested that current management of PH in VLBW infants includes ventilatory support using high positive end expiratory pressure, transfusion of blood and blood products to support the circulation and correct any hemostatic or coagulation defects and evaluation and treatment for patent ductus arteriousus (PDA). These strategies are often ineffective in preventing a poor outcome. rFVIIa is effective in controlling life-threatening hemorrhage in patients with hemophilia A and B with inhibitors, and in nonhemophiliacs with a variety of inherited or acquired hemostatic defects including platelet disorders, liver disease and von Willebrand's disease.(15a)

 2. Embolization - Interventional treatment of pulmonary arteriovenous malformations
Acording to the study of Dr. Andersen PE and Dr. Kjeldsen AD. at the Odense University Hospital " Pulmonary arteriovenous malformations (PAVM) are congenital vascular communications in the lungs.  The generally accepted treatment strategy of first choice is embolization of the afferent arteries to the arteriovenous malformations. It is a minimally invasive procedure and at the same time a lung preserving treatment with a very high technical success, high effectiveness and low morbidity and mortality. Embolization prevents cerebral stroke and abscess as well as pulmonary haemorrhage and further raises the functional level. Embolization is a well-established method of treating PAVM, with a significant effect on oxygenation of the blood. Screening for PAVM in patients at risk is recommended, especially in patients with HHT(16).

3. Corticosteroids 
There is a report of a patient suffered from acute glomerulonephritis with modest renal impairment and life-threatening pulmonary hemorrhage. The pulmonary hemorrhage caused severe hypoxia that necessitated artificial ventilation. As a last resort, 1 g/day of methylprednisolone was administered intravenously. Rapid cessation of pulmonary hemorrhage ensued with clearing of the lungs fields. the suggestion of large doses of glucocorticosteroids should be administered to patients with life-threatening pulmonary hemorrhage before considering bilateral nephrectomy, especially if the renal function is still adequate. Bilateral nephrectomy is an irreversible approach and, as with massive doses of steroids, has yet to be proved to be a consistently effective mode of therapy(17).

4. Etc. 

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Sources
(12) http://saithan.net/pulmonary%20and%20sys%20disease/Pulmonary%20complications%20of%20leptospirosis.pdf 
(13) http://ape.med.miami.edu/Doc/Resident%20Web%20Site%20Articles/Other%20diseases/Hereditary%20Hemorrhagic%20Telangiectasias/OB%20article%20+%20pulmAVMs.pdf
(14) http://www.ncbi.nlm.nih.gov/pubmed/22683446 
(15) http://www.ucsfbenioffchildrens.org/pdf/manuals/29_PulmHemorrhage.pdf
(15a) http://www.nature.com/jp/journal/v22/n8/full/7210787a.html
(16) http://www.ncbi.nlm.nih.gov/pubmed/21160695 
(17) http://annals.org/article.aspx?articleid=689575