Capillary bleeding under oral anticoagulation.

BACKGROUND: Oral anticoagulants are routinely used for prevention of thromboembolism in cardiac, arterial or venous diseases. Hemorrhages are serious treatment complications, frequently occurring under long-term and/or high-dose regiments. From animal experiments it is known that coumarin-type anticoagulants may cause capillary dilatation and increased permeability, red blood cell extravasation and punctate bleeding. Controlled human trials are lacking. METHODS: 31 patients under oral anticoagulation were examined by video capillary microscopy. 52 patients with comparable diseases and treatment but without oral anticoagulation served as controls. Nailfold capillaries of four fingers of each hand were examined and analyzed off-line according to the following criteria: (1) numbers of capillaries investigated, (2) numbers of capillary bleedings, and (3) bleeding incidence (bleedings per 100 capillaries). RESULTS: In 23 out of 31 patients (74.2%) capillary bleedings were observed. The bleeding incidence ranged from 0.33 to 4.29 per 100 capillaries. In contrast, only 4 out of 52 controls were detected with capillary bleedings (2.1%, p<0.001). The bleeding incidence was 0.34-2.41. In patients on anticoagulation there was no correlation between the number of capillary bleedings and the INR or Quick values. During a two year follow-up of patients on oral anticoagulation no significant difference was found in terms of clinically obvious bleedings in patients with or without capillary bleedings. CONCLUSION: This study shows that capillary bleedings can be demonstrated in patients on oral anticoagulation. Bleedings occur independent of the INR-value. Thus, other factors than the vitamin-k-dependent coagulation effect seem to be causal for the damage of microvessels. Further, the evidence of capillary bleedings is not a prognostic indicator for future hemorrhage.

Effects of an onion-olive oil maceration product containing essential ingredients of the Mediterranean diet on blood pressure and blood fluidity.

Twenty-four patients with arterial hypertension (WHO class I) received either 4 capsules of an onion-olive oil maceration product, containing essential ingredients of the Mediterranean diet, or placebo daily over a period of one week. In order to investigate the acute effect on arterial blood pressure, measurements were performed before and 5 h after the administration of the first dose of 4 capsules verum or placebo, respectively. For the evaluation of the long term effect further blood pressure measurements were performed after one week's treatment with a daily dose of 4 capsules. After a wash-out phase of 2 weeks followed by a crossover, the second study phase, which was identical in design, was carried out. In addition patients were instructed to measure their blood pressure 4 times daily at home for the whole study period. Haemorheological parameters (platelet aggregation, erythrocyte aggregation, plasma viscosity and haematocrit) were also determined at the measuring points mentioned above. The onion-olive oil maceration product led to a significant decrease in systolic blood pressure. There was also a trend towards a decrease in diastolic blood pressure. The improved blood fluidity observed resulted from a decrease in haematocrit. All effects could be shown immediately and after one week's administration.

Influence of the onion as an essential ingredient of the Mediterranean diet on arterial blood pressure and blood fluidity.

Mediterranean diet has got a favourable effect on life expectancy. One of the crucial components of the diet are onions. In an open and a randomized, placebo-controlled, double-blind, cross-over phase-I study a spontaneous pharmacological effect 5 h after administration of an onion-olive-oil maceration capsule formulation on arterial blood pressure could be demonstrated in apparently healthy subjects. In addition to a decrease in arterial blood pressure, a significant reduction in plasma viscosity and haematocrit were observed. These results are indicating a vasodilative effect of the onion-olive-oil-maceration product. The stickiness of the platelets was reduced. The effects were stronger in subjects with reduced blood fluidity compared to those subjects with normal rheological parameters.

The use of prothrombin complex concentrates in the treatment of hemorrhages induced by oral anticoagulation.

Bleeding events are a common adverse effect in oral anticoagulation that frequently depend on the duration and intensity of treatment. Major bleeding events, particularly intracerebral hemorrhages, are a serious complication in cases that require the rapid reversal of anticoagulation. Urgent correction of the coagulation defect is also indicated when major emergency surgery is necessary. In addition to vitamin K supplementation, the administration of prothrombin complex concentrates is the most effective measure for the rapid reversal of anticoagulation. Due to the time-consuming administration and increased risk of volume overload, the administration of fresh frozen plasma is less advisable in such instances. The application of prothrombin complex concentrates requires a precautious risk-benefit evaluation, including an estimation of contraindications and repeated laboratory monitoring for dose adjustment.

[Autotransfusion with leap-frog technique in patients with coronary heart disease and planned aortocoronary venous bypass]. / Autotransfusion in Bocksprung-Technik bei Patienten mit koronarer Herzkrankheit und geplantem aortokoronarem Venenbypass.

OBJECTIVE: The goal of the study is to test and control the quality of a special leap-frog technique which enables saving heterologous blood. DESIGN: In a randomized double-blind placebo-controlled study homologous blood was taken in 40 out of 100 patients with coronary heart disease before aortocoronary bypass operation. The leap-frog technique was used. Within 8 weeks 3-4 erythrocyte concentrates and 0.9-1.2 liters plasma were sampled. The volume (verum: HES 200/0.5 10%; placebo: 0.9% NaCl solution) substituted corresponding to the volume of blood donated. Each patient received 200 mg Fe2+/day p.o. RESULTS: Clinically, only patients treated with HES in stage of autologous blood sampling benefited significantly. Two patients showed adverse effects. The peri- and postoperative course was comparable. In the NaCl group one of the patients received homologous erythrocyte concentrates. None of the patients died pre-, peri- or post-operatively. CONCLUSIONS: 40% of the cardiosurgical patients could be considered for autologous blood donation. Isovolemic hemodilution with HES 200/0.5 10% was a suitable and safe measure in preoperative blood sampling. Physical exercise should be performed before and after autologous blood donation. A reduced exercise tolerance suggests that autologous blood donation should be stopped.

[Autotransfusion using the bocksprung technique in patients with coronary heart disease and coronary artery bypass grafting]. / Autotransfusion in Bocksprungtechnik bei Patienten mit koronarer Herzkrankheit und geplantem aortokoronarem Venenbypass.

Clinically, only patients treated with HES in stage of autologous blood sampling benefited significantly. Two patients showed adverse effects. The peri- and postoperative course was comparable. In the NaCl group one of the patients received homologous erythrocyte concentrates. None of the patients died pre-, peri- or postoperatively. 40% of the cardiosurgical patients could be considered for autologous blood donation. Isovolemic hemodilution with HES 200/0.5 10% was a suitable and safe measure in preoperative blood sampling. Physical exercise test should be performed before and after autologous blood donation. A reduced exercise tolerance suggests to stop autologous blood donation.

[Quality assurance in autologous blood collection from critically ill patients]. / Qualitätssicherung bei der Eigenblutentnahme von kritisch Kranken.

Quality controls of autologous blood collections in critically ill patients comprise the control of blood products, blood collection, and of the patients themselves. The control of products is defined in European guidelines, the AMG (law governing the manufacture and prescription of medicine) and GMP regulations. The products are described in the monograph of the Federal Health Office. The quality control of blood collection in patients with a critical vascular disease is important since vagotonic or hypertensive crises may occur frequently (in 10-15% of cardiosurgical patients). The quality control of the critically ill patients themselves is important in order to be able to balance benefits against risks. A phlebotomy of 500 ml may lead to a considerable deterioration of the clinical condition. The clinical condition can be controlled by simple exercise tests prior to and after the blood collection (bicycle ergometer, treadmill or climbing stairs). In our own investigations only about 25% of cardiosurgical patients (40% of patients with aortocoronary venous bypass) received autohemotherapy, and 20% of them showed a clinical deterioration during the phase of blood collection. Other problematic patients are those suffering from a tumor. A clear clinical benefit of autohemotherapy in these patients has not been demonstrated up to now; nevertheless, when a curative therapy is possible, they should be treated with autohemotherapy.

Comparison of the effects of sodium pentosanpolysulfate and unfractionated heparin on venous thrombosis; an experimental study in rats.

Sodium pentosanpolysulfate (Fibrezym) and unfractionated heparin (Liquemin) had significant antithrombotic efficacy in rats. 1 mg/kg body weight (BW) FibrezymR had its maximal effect 2-4 hours after subcutaneous administration; 200 U/kg BW LiqueminR s.c. were most effective 4-6 hours after application. Both drugs caused frequent embolic break-offs of thrombi during the time periods of maximal antithrombotic efficiency.

Influence of garlic powder on cutaneous microcirculation. A randomized placebo-controlled double-blind cross-over study in apparently healthy subjects.

In a randomized placebo-controlled double-blind cross-over study it could be shown that 5 h after the administration of garlic powder (Kwai, Sapec; total dose of 900 mg garlic powder) a significant increase in capillary skin perfusion by 55% occurs in the healthy volunteers. Placebo did not cause any changes. The difference between the two study phases is also significant. The increased erythrocyte velocity results from vasodilation of precapillary arterioles which increases diameter of erythrocyte column by an average of 8.6%. Simultaneously inflow of interstitial fluidity accompanied by a significant decrease in haematocrit and plasma viscosity occurs (rheoregulation).

Effect of garlic on thrombocyte aggregation, microcirculation, and other risk factors.

Significant positive effects could be achieved in a placebo-controlled double-blind study through the administration of 800 mg of garlic powder over a period of four weeks. Spontaneous thrombocyte aggregation disappeared, the microcirculation of the skin increased by 47.6% (from 0.63 +/- 0.13 to 0.93 +/- 0.22 mm/s), plasma viscosity decreased by 3.2% (from 1.25 +/- 0.34 to 1.21 +/- 0.43 mPas), diastolic blood pressure by 9.5% (from 74 +/- 9 to 67 +/- 5 mmHg), and blood glucose concentration by 11.6% (from 89.4 +/- 8.8 to 79.0 +/- 11.9 mg/dl). The vascular protection of garlic as atherosclerosis prevention by influencing the mentioned risk parameters for cardiovascular diseases must be pointed out. Especially interesting is the thrombocyte aggregation inhibiting effect. Thus, the application of garlic may be useful in case of acetylsalicyclic acid intolerance.

Effects of garlic on blood fluidity and fibrinolytic activity: a randomised, placebo-controlled, double-blind study.

In summary, it can be said that the improvement of blood fluidity and the simultaneous increase in fibrinolytic activity are an ideal complement. While the increase in fibrinolytic activity supports the physiological reparation process in the microcirculation, the improvement of blood fluidity produces an increase in capillary perfusion that has, in some way, a cleaning effect, with a 'purification' of the microcirculation.