Altered Fibrinolysis during and after Surgery.

Major surgery induces hemostatic changes related to surgical stress, tissue destruction, and inflammatory reactions. These changes involve a shift of volume from extravascular space to intravascular and interstitial spaces, a "physiologic" hemodilution of coagulation proteins, and an increase of plasmatic fibrinogen concentration and platelets. Increases in fibrinogen and platelets together with a simultaneous dilution of pro- and anticoagulant factors and development of a hypofibrinolytic status result in a postoperative hypercoagulable state. This profile is accentuated in more extensive surgery, but the balance can shift toward hemorrhagic tendency in specific types of surgeries, for example, in prolonged cardiopulmonary bypass or in patients with comorbidities, especially liver diseases, sepsis, and hematological disorders. Also, acquired coagulopathy can develop in patients with trauma, during obstetric complications, and during major surgery as a result of excessive blood loss and subsequent consumption of coagulation factors as well as hemodilution. In addition, an increasing number of patients receive anticoagulants and antiplatelet drugs preoperatively that might influence the response to surgical hemostasis. This review focuses on those situations that may change normal hemostasis and coagulation during surgery, producing both hyperfibrinolysis and hypofibrinolysis, such as overcorrection with coagulation factors, bleeding and hyperfibrinolysis that may occur with extracorporeal circulation and high aortic-portal-vena cava clamps, and hyperfibrinolysis related to severe maintained hemodynamic disturbances. We also evaluate the role of tranexamic acid for prophylaxis and treatment in different surgical settings, and finally the value of point-of-care testing in the operating room is commented with regard to investigation of fibrinolysis.

Enhanced recovery after surgery: a narrative review on patient blood management recommendations.

This review aims to analyze and document the presence of patient blood management (PBM) recommendations in enhanced recovery after surgery (ERAS) guidelines. The aim of ERAS programs is to improve outcomes and optimize patient recovery by reducing the stress response to surgery. PBM programs pursue the objective of improving outcomes by boosting and conserving the patient's own blood. From the early development of ERAS, there was little attention paid to the three pillars of perioperative blood management. Preoperative anemia is an important risk factor in perioperative outcomes and should be diagnosed and treated. Bleeding and unnecessary transfusions should be avoided. We analyzed clinical guidelines for scheduled surgery in adults published by the ERAS Society between 2018 and 2022. The guidelines selected were searched for recommendations related to the three pillars of PBM. We selected 15 ERAS guidelines in programmed surgery in adults. Until 2018, none of the ERAS guidelines analyzed included any recommendations related to pillars I and III of PBM. In 2019, recommendations related to the three pillars of PBM were introduced in the ERAS clinical guidelines for colorectal surgery, gynecology/oncology surgery, and lung resection surgery. However, many ERAS guidelines for surgeries with a high risk of bleeding, such as cardiac surgery, contain no clear recommendations on the management of preoperative anemia. This review shows that the ERAS guidelines published to date make very few recommendations related to PBM. The authors emphasize the need to include the most efficient PBM recommendations in ERAS clinical guidelines, given improved outcomes with a good perioperative management of blood transfusion.

Clinical use of tranexamic acid: evidences and controversies

Abstract Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.

[What is "coping"?]. / Qué es el afrontamiento?

The objective of this article is to analyze the concept of confrontation, especially how cancer patients apply it as related to their disease. To this end, the authors study empirical evidence from patients who are undergoing treatment for cancer. The authors evaluate the uses, attributes, antecedents and consequences of the concept of confrontation. Furthermore, the authors present different conceptual and operational definitions of confrontation.

Síndrome de Turner en una adolescente / Turner syndrome in an adolescent

Se presenta el caso clínico de una adolescente ecuatoriana de 17 años de edad, blanca, quien nació producto de un embarazo normal y parto eutócico. Posterior al nacimiento se le realizó estudio genético que mostró la presencia de un cariotipo X0, por lo cual se le diagnosticó síndrome de Turner. A los 3 años fue operada de hipoplasia del arco aórtico con una evolución favorable. En la actualidad la paciente tiene baja talla con orejas de baja implantación, así como implantación alta del cabello en la nuca, tórax plano en forma de escudo, escaso bello pubiano y ausencia de menstruación

The case report of a 17 years Ecuadorian white adolescent is presented who was born from a normal pregnancy and eutocic delivery. After birth, a genetic study that showed the presence of a X0 Karyotype was carried out, reason why she was diagnosed Turner syndrome. She was operated of hypoplastic aortic arch when she was 3 years with a favorable clinical course. At the present time the patient has short height with ears of low implantation, as well as high implantation of the hair in the back of the neck, flat thorax in shield form, scarce pubic hair and amenorrhea

¿Qué es el afrontamiento? / What is confrontation?

El propósito de este trabajo es analizar el concepto de afrontamiento, especialmente cómo los pacientes con cáncer lo aplican en su enfermedad. Para ello se revisa la evidencia empírica en pacientes que están recibiendo tratamiento para el cáncer. Se evalúan los usos, atributos, antecedentes y consecuencias del concepto de afrontamiento. Además, se presentan las diferentes definiciones conceptuales y operacionales del afrontamiento (AU)

Análisis empírico del concepto de afrontamiento / Empirical analysis of the concept of coping

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