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1.
J Pharm Pract ; : 8971900211044288, 2021 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-34569328

RESUMO

The growing use of oral factor Xa (FXa) inhibitors in patients with chronic kidney disease (CKD), particularly the recent increased use of apixaban in patients with end-stage renal disease (ESRD), has created a new dilemma in the already controversial topic of oral FXa inhibitor reversal. With the limited availability of anti-Xa levels specific to oral FXa inhibitors and even scarcer availability of reversal data for patients on these agents with ESRD, ensuring adequate reversal is currently often solely guided by repeat imaging and changes in clinical status. Low molecular weight heparin (LMWH) anti-Xa levels have been used as a more commonly accessible test to guide the need for and efficacy of reversal of oral FXa inhibitors in patients with normal renal function. However, evidence supporting this technique is again lacking in patients with renal dysfunction. This case report focuses on the use of LMWH anti-Xa levels to guide reversal of apixaban in a patient with ESRD on hemodialysis and correlation of those levels to the patient's clinical status.

2.
Am J Emerg Med ; 2021 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-34244010

RESUMO

Rivaroxaban is a direct oral anticoagulant (DOAC) used for prophylaxis and treatment of many prothrombotic states. The anticoagulation effects of rivaroxaban are produced by selectively binding and inhibiting factor Xa, causing delayed thrombin generation. Additionally, the delay in thrombin generation produces an indirect, dose dependent antiplatelet effect via reduction in tissue factor platelet aggregation. As with any anticoagulant, rivaroxaban use increases a patient's risk for major and minor hemorrhagic events. With mortality rates reported as high as 25% for those who experience an intracranial hemorrhage (ICH), immediate mitigation of hematoma and hemorrhage volume expansion is imperative. Management strategies include utilizing prothrombin complex concentrates (PCC) and factor Xa inhibitor specific antidotes, such as coagulation factor Xa recombinant, inactivated-zhzo. Routine monitoring or management of DOAC induced antiplatelet effects is ill-defined and not a part of routine standard of care. We report the first case, to our knowledge, of rivaroxaban's indirect antiplatelet effects identified by platelet function assays and managed with four-factor PCC and desmopressin in a patient experiencing an ICH. Further exploration is needed to determine the true clinical impact attributed to rivaroxaban's antiplatelet effects.

3.
Am J Emerg Med ; 49: 200-205, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34139435

RESUMO

The year 2020 was not easy for Emergency Medicine (EM) clinicians with the burden of tackling a pandemic. A large focus, rightfully so, was placed on the evolving diagnosis and management of patients with COVID-19 and, as such, the ability of clinicians to remain up to date on key EM pharmacotherapy literature may have been compromised. This article reviews the most important EM pharmacotherapy publications indexed in 2020. A modified Delphi approach was utilized for selected journals to identify the most impactful EM pharmacotherapy studies. A total of fifteen articles, eleven trials and four meta-analyses, were identified. This review provides a summary of each study, along with a commentary on the impact to the EM literature and EM clinician.


Assuntos
COVID-19/epidemiologia , Tratamento Farmacológico , Medicina de Emergência , Bibliometria , Humanos , Publicações Periódicas como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , SARS-CoV-2
4.
Am J Health Syst Pharm ; 78(15): 1382-1384, 2021 07 22.
Artigo em Inglês | MEDLINE | ID: mdl-33895798

RESUMO

PURPOSE: This case report describes utilization of thromboelastography (TEG) in the setting of an acute major bleed in a patient on dabigatran who had concomitant acute kidney injury. SUMMARY: An 80-year-old female presented to the emergency department after a fall with complaints of pain in her knee, shoulder, and hip. Her medical history was significant for coronary artery disease, for which she took clopidogrel 75 mg daily, and atrial fibrillation, for which she took dabigatran 150 mg twice daily. The physical exam was remarkable for pain within the shoulder, hip, and knee, which had swelling and ecchymosis that extended into the right thigh. Given the possibility of compartment syndrome with multiple possible etiologies of coagulopathy, TEG and computed tomography angiography (CTa) of the right lower extremity were performed. The initial TEG showed prolonged R time and activated clotting time, indicating clotting factor dysfunction with no additional coagulopathy noted, including antiplatelet effects. On the basis of the TEG and CTa findings, it was decided to reverse dabigatran with 5 grams of idarucizumab. Approximately 1 hour after administration of idarucizumab, the patient was taken to interventional radiology where a limited angiogram of the right lower extremity showed no active extravasation. Because of the patient's renal dysfunction and the possibility of rebound hypercoaguability, repeat TEG tests were ordered at 4 and 8 hours after the initial reversal to ensure clearance of idarucizumab-dabigatran complexes. The repeat TEG values showed complete reversal of the initial coagulopathy noted. During the admission, the patient required no blood transfusions or surgical interventions and all her initial laboratory results improved. CONCLUSION: Serial TEG testing was successful at managing multiple coagulopathies in a patient at risk for trauma-induced compartment syndrome.


Assuntos
Injúria Renal Aguda , Fibrilação Atrial , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/tratamento farmacológico , Idoso de 80 Anos ou mais , Dabigatrana/efeitos adversos , Feminino , Hemorragia , Humanos , Tromboelastografia
8.
J Pharm Pract ; 34(5): 755-760, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32089040

RESUMO

OBJECTIVE: In cases of oral factor Xa (FXa) inhibitor-associated acute major bleeding, several reversal strategies are available. Current guidelines recommend a dose of 50 U/kg if using 4-factor prothrombin complex concentrate (4F-PCC). A paucity of data exists with the use of 4F-PCC for FXa inhibitor reversal for acute major bleeding, specifically the most efficacious dosing regimens and safety data. The purpose of this case series is to describe the utilization of 4F-PCC for reversal of oral FXa inhibitor-associated acute major bleeding. METHODS: This retrospective case series included all admitted patients 18 years and older who received 4F-PCC for oral FXa inhibitor-associated major bleeding. Major bleeding was defined using the International Society of Thrombosis and Hemostasis definition for major bleeding in nonsurgical patients. The primary outcome was achievement of hemostasis. RESULTS: A total of 31 patients met inclusion criteria, with 17 receiving rivaroxaban and 14 receiving apixaban. Intracranial hemorrhage was the most common type of bleeding occurring in 15 (55%) patients. The median dose of 4F-PCC was 37 U/kg. Of the patients evaluated in the primary end point analysis, 68% achieved effective hemostasis. Four (12.9%) patients experienced a documented thrombotic event within 7 days of receiving 4F-PCC. CONCLUSION: The use of 4F-PCC for FXa inhibitor-associated acute major bleeding was effective for the majority of patients. The rate of thrombotic events appears higher compared to previously published studies, although major confounders exist and larger studies are needed to fully evaluate the safety of 4F-PCC for this indication.


Assuntos
Fatores de Coagulação Sanguínea , Inibidores do Fator Xa , Anticoagulantes , Inibidores do Fator Xa/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Humanos , Estudos Retrospectivos
9.
Crit Care Nurse ; 40(3): e9-e16, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-32476028

RESUMO

BACKGROUND: Paroxysmal sympathetic hyperactivity, which affects up to 10% of all acquired brain injury survivors, is characterized by elevated heart rate, blood pressure, respiratory rate, and temperature; diaphoresis; and increased posturing. Pharmacological agents that have been studied in the management of this disorder include opiates, γ-aminobutyric acid agents, dopaminergic agents, and ß blockers. Although paroxysmal sympathetic hyperactivity is a relatively common complication after acquired brain injury, there is a paucity of recommendations or comparisons of agents for the management of this disorder. OBJECTIVE: To evaluate all relevant literature on pharmacological therapies used to manage patients with paroxysmal sympathetic hyperactivity to help elucidate possible best practices. METHODS: Of the 27 studies evaluated for inclusion, 10 studies received full review: 4 retrospective cohort studies, 5 single case studies, and 1 case series. RESULTS: Monotherapy is usually not effective in the management of paroxysmal sympathetic hyperactivity and multiple agents with different mechanisms of action should be considered. α2-Agonists such as dexmedetomidine may hold some slight clinical efficacy over agents like propofol, and with respect to oral medications, propranolol might convey some slight advantage compared to others. However, with the limited data available, these results must be interpreted with caution. CONCLUSIONS: As the treatment of paroxysmal sympathetic hyperactivity is reactive to symptomatic evolution over time, critical care nurses play a vital role in the monitoring and treatment of these patients. Limited data exist on the management of paroxysmal sympathetic hyperactivity and larger robust data sets are needed to guide decision-making. (Critical Care Nurse. 2020;40[3]:e9-e16).


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Doenças do Sistema Nervoso Autônomo/tratamento farmacológico , Doenças do Sistema Nervoso Autônomo/etiologia , Doenças do Sistema Nervoso Autônomo/enfermagem , Lesões Encefálicas/complicações , Enfermagem de Cuidados Críticos/educação , Enfermagem de Cuidados Críticos/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Currículo , Educação Continuada em Enfermagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Resultado do Tratamento
10.
J Emerg Med ; 59(2): 201-215, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32418869

RESUMO

BACKGROUND: Viscoelastography (VE) is an established method to identify coagulopathies in various disease processes. Clinical decisions can be made with real-time tracings and quantitative values at the bedside. Thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) have been utilized in several disease states with clinical varying success. OBJECTIVES: This review will summarize the literature and provide recommendations pertaining to major disease processes where VE may be beneficial, including trauma, anticoagulation reversal, liver disease, acute ischemic stroke, and acquired brain injuries. DISCUSSION: VE has a role in many emergency medicine patients encountered by clinicians. Reduced mortality, decreased blood product utilization, and prognostication ability makes VE an intriguing tool that can be utilized by providers to improve patient care. CONCLUSION: This review serves as a way for emergency medicine clinicians to utilize VE in their practice and provides an insightful literature overview.


Assuntos
Transtornos da Coagulação Sanguínea , Isquemia Encefálica , Medicina de Emergência , Acidente Vascular Cerebral , Transtornos da Coagulação Sanguínea/diagnóstico , Humanos , Tromboelastografia
11.
J Pediatr Intensive Care ; 9(1): 64-69, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31984161

RESUMO

We report a case of pharmacologic management of pediatric paroxysmal sympathetic hyperactivity (PSH) in a patient who experienced symptomatic resolution with dexmedetomidine and propranolol. Following a blunt traumatic subdural hematoma and diffuse axonal injury, an 8-year-old male developed PSH on approximately day 5 of the hospitalization. PSH symptoms identified in this patient were hyperthermia, tachycardia, posturing, and hypertension with associated elevations in intracranial pressure. Episodes of PSH continued to be observed despite appropriate titration of opiates, sedatives, and traditional blood pressure management. Dexmedetomidine and propranolol were subsequently initiated to attenuate acute episodes of PSH. A reduction in sedative requirements and improvement in symptoms followed, which facilitated successful extubation. The combination of propranolol and dexmedetomidine was followed by a decrease in the frequency and severity of acute episodes of PSH. After utilization of multiple treatment modalities to control PSH episodes in our patient, propranolol and dexmedetomidine may have helped attenuate PSH signs and symptoms.

15.
Am J Emerg Med ; 38(4): 806-809, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31864879

RESUMO

BACKGROUND: Dosing of four factor prothrombin complex concentrate (4PCC) for warfarin reversal remains controversial. Recently, the American College of Cardiology (ACC) recommended a low-dose PCC regimen as an option for warfarin reversal in acute major bleeding. We performed a retrospective study evaluating if a modified version of the ACC guideline recommendations was effective for warfarin reversal in acute major bleeds when compared to traditional variable dosing. METHODS: This was a retrospective cohort study of patients who received 4PCC for warfarin reversal in a 12 month period. We included patients that were ≥18 years of age, received 4PCC for warfarin reversal, and had an initial International Normalized Ratio (INR) of >2. Our primary outcome was the number of patients who had a post-4PCC infusion INR of <1.6. RESULTS: A total of 60 patients were included in the final analysis with 30 patients stratified to the traditional dosing and low-dose groups, respectively. Patient demographics were similar between both groups. We found no difference in the number of patients who had a post-4PCC infusion INR <1.6 between the traditional dosing and low dosing group (90.0% vs. 86.7%; p = 0.68). Additionally, we found no difference between post-infusion median INRs in each group (1.35 vs. 1.30; p = 0.16). Approximately 1000 units per patient were spared when utilizing the low-dose regimen. CONCLUSION: A modified version of the ACC's low-dose 4PCC option for warfarin reversal achieves similar outcomes for lowering INR values compared to traditional variable dosing regimens.


Assuntos
Anticoagulantes/efeitos adversos , Fatores de Coagulação Sanguínea/administração & dosagem , Varfarina/antagonistas & inibidores , Idoso , Idoso de 80 Anos ou mais , Fatores de Coagulação Sanguínea/uso terapêutico , Feminino , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Resultado do Tratamento , Varfarina/efeitos adversos
16.
Clin Ther ; 41(12): 2594-2610, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31668356

RESUMO

PURPOSE: Angiotensin II (ATII) is a potent endogenous vasoconstrictor that has recently garnered regulatory approval for the treatment of distributive shock, including septic shock. Traditional vasoactive substances used in the management of distributive shock include norepinephrine, epinephrine, phenylephrine, and vasopressin. However, their use can be associated with deleterious adverse drug effects, such as splanchnic vasoconstriction and associated hypoperfusion. The purpose of this review is to describe ATII, including its pharmacologic mechanisms, pharmacokinetic profile, evidence of efficacy and tolerability, and potential role in contemporary critical care practice. METHODS: Peer-reviewed clinical trials and relevant treatment guidelines published from 1966 to September 14, 2019, were identified from Medline/PubMed using the following search terms: angiotensin II OR angiotensin 2 AND shock OR septic shock OR vasodilatory shock. Pertinent review articles were reviewed for additional studies for inclusion and discussion. The final decision on the inclusion of studies in the current review was based on the expert opinion of the authors. FINDINGS: On the basis of the available evidence, ATII is effective at elevating blood pressure in patients with distributive shock and appears to reduce the dose of concurrent vasopressors to maintain adequate blood pressure. ATII has been investigated for other causes of shock; however, robust evidence of off-label indications is lacking and is much needed. Clinical and cost benefits compared with traditional vasopressors have yet to be established. IMPLICATIONS: ATII represents a welcome addition to the armamentarium of critical care clinicians. Enthusiasm for the use of ATII should be balanced with the current gaps in our understanding of ATII in patients with shock. Until further evidence provides more clinically meaningful benefits, as well as cost-effectiveness compared with currently available vasopressors, critical care clinicians should reserve ATII for salvage therapy in patients with septic shock.


Assuntos
Angiotensina II , Choque/tratamento farmacológico , Vasoconstritores , Cuidados Críticos , Humanos
18.
Am J Emerg Med ; 37(10): 1991.e1-1991.e3, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31375354

RESUMO

Reversal of oral factor Xa (FXa) inhibitors, such as apixaban, remains a controversial topic. However, the controversy goes beyond what reversal agent to utilize. Often times these patients present with an acute major bleed and are difficult to assess whether reversal is warranted or not. Furthermore, it is difficult to assess whether reversal was successful in a timely manner. A paucity of literature exists regarding the utilization of low molecular weight heparin (LMWH) anti-Xa assays and thromboelastography for identifying coagulopathies associated with oral FXa inhibitors. We report a case of apixaban induced coagulopathy utilizing thromboelastography and a LMWH anti-Xa assay as a guide for reversal.


Assuntos
Inibidores do Fator Xa/efeitos adversos , Hemorragia/induzido quimicamente , Heparina de Baixo Peso Molecular/uso terapêutico , Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Tromboelastografia , Idoso de 80 Anos ou mais , Inibidores do Fator Xa/farmacologia , Guias como Assunto , Humanos , Masculino
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