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J Thromb Haemost ; 18(10): 2457-2467, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32638483


Prothrombin complex concentrate (PCC) is increasingly being used as a treatment for major bleeding in patients who are not taking anticoagulants. The aim of this systematic review and meta-analysis is to evaluate the effectiveness of PCC administration for the treatment of bleeding in patients not taking anticoagulants. Studies investigating the effectivity of PCC to treat bleeding in adult patients and providing data on either mortality or blood loss were eligible. Data were pooled using Mantel-Haenszel random effects meta-analysis or inverse variance random effects meta-analysis. From 4668 identified studies, 17 observational studies were included. In all patient groups combined, PCC administration was not associated with mortality (odds ratio = 0.83; 95% confidence interval [CI], 0.66-1.06; P = .13; I2  = 0%). However, in trauma patients, PCC administration, in addition to fresh frozen plasma, was associated with reduced mortality (odds ratio = 0.64; CI, 0.46-0.88; P = .007; I2  = 0%). PCC administration was associated with a reduction in blood loss in cardiac surgery patients (mean difference: -384; CI, -640 to -128, P = .003, I2  = 81%) and a decreased need for red blood cell transfusions when compared with standard care across a wide range of bleeding patients not taking anticoagulants (mean difference: -1.80; CI, -3.22 to -0.38; P = .01; I2  = 92%). In conclusion, PCC administration was not associated with reduced mortality in the whole cohort but did reduce mortality in trauma patients. In bleeding patients, PCC reduced the need for red blood cell transfusions when compared with treatment strategies not involving PCC. In bleeding cardiac surgery patients, PCC administration reduced blood loss.

Fatores de Coagulação Sanguínea , Hemorragia , Adulto , Anticoagulantes/efeitos adversos , Fatores de Coagulação Sanguínea/uso terapêutico , Fator IX , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Humanos , Plasma , Estudos Retrospectivos
Anesthesiology ; 123(4): 820-9, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26263429


BACKGROUND: The authors investigated whether patients with out-of-hospital cardiac arrest with an initial low cerebral oxygen level during cardiopulmonary resuscitation are more prone to develop hyperfibrinolysis than patients with normal cerebral oxygenation levels and which part of the fibrinolytic system is involved in this response. METHODS: In 46 patients, hyperfibrinolysis was diagnosed immediately upon emergency department admission using rotational thromboelastometry and defined as a lysis more than 15%. Simultaneously, initial cerebral tissue oxygenation was measured using near-infrared spectroscopy, and oxygen desaturation was defined as a tissue oxygenation index (TOI) of 50% or less. Blood sample analysis included markers for hypoperfusion and fibrinolysis. RESULTS: There was no difference in prehospital cardiopulmonary resuscitation duration between patients with or without hyperfibrinolysis. An initial TOI of 50% or less was associated with more clot lysis (91% [17 to 100%; n = 16]) compared with patients with a normal TOI (6% [4 to 11%]; n = 30; P < 0.001), with lower levels of plasminogen (151.6 ± 61.0 vs. 225.3 ± 47.0 µg/ml; P < 0.001) and higher levels of tissue plasminogen activator (t-PA; 18.3 ± 7.4 vs. 7.9 ± 4.7 ng/ml; P < 0.001) and plasminogen activator inhibitor-1 (19.3 ± 8.9 vs. 12.1 ± 6.1 ng/ml; P = 0.013). There were no differences in (activated) protein C levels among groups. The initial TOI was negatively correlated with t-PA (r = -0.69; P < 0001). Mortality rates were highest in patients with hyperfibrinolysis. CONCLUSION: Activation of the fibrinolytic system is more common in out-of-hospital cardiac arrest patients with an initial cerebral tissue oxygenation value of 50% or less during resuscitation and is linked to increased levels of t-PA rather than involvement of protein C.

Encéfalo/metabolismo , Fibrinólise/fisiologia , Parada Cardíaca Extra-Hospitalar/metabolismo , Parada Cardíaca Extra-Hospitalar/terapia , Consumo de Oxigênio/fisiologia , Ressuscitação/tendências , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/complicações , Estudos Prospectivos
Anesthesiology ; 121(1): 89-97, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24646494


BACKGROUND: Rotational thromboelastometry is increasingly used to detect hyperfibrinolysis, which is a predictor of unfavorable outcome in patients with coagulation disturbances. In an in vitro study, the authors investigated which thromboelastometric hemostatic parameters could be valuable for fast diagnosis of the severity of hyperfibrinolysis and confirmed their findings in a patient population with hyperfibrinolysis. METHODS: Thromboelastometry was performed after adding increasing concentrations of tissue plasminogen activator (0 to 400 ng/ml) to citrated blood samples of 15 healthy volunteers. Lysis parameters included the clotting time, maximum clot firmness, maximum lysis, and lysis onset time (LOT). The relation of tissue plasminogen activator with the LOT was further investigated in a patient population with out-of-hospital cardiac arrest and hyperfibrinolysis. RESULTS: The LOT showed a dose-dependent association with increasing tissue plasminogen activator concentrations. Late, intermediate, or fulminant hyperfibrinolysis was associated with an average LOT (mean ± SD) of 42.7 ± 13.8, 23.2 ± 8.2, and 17.5 ± 4.6 min in the in vitro study and estimated 42.2 ± 8.3, 29.1 ± 1.2, and 14.6 ± 7.7 min in patients, respectively. The authors found a moderately negative correlation between patient plasma tissue plasminogen activator levels and the LOT (r = -0.67; P = 0.01). CONCLUSION: This study shows that the LOT may be used for fast detection of severe hyperfibrinolysis, with a better resolution than the maximum lysis, and should be further evaluated for optimization of therapeutic strategies in patients with severe clot breakdown.

Fibrinólise/fisiologia , Tromboelastografia/métodos , Adulto , Idoso , Tempo de Circulação Sanguínea/efeitos dos fármacos , Reanimação Cardiopulmonar , Relação Dose-Resposta a Droga , Feminino , Fibrinólise/efeitos dos fármacos , Parada Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Agregação Plaquetária , Estudos Prospectivos , Valores de Referência , Ativador de Plasminogênio Tecidual/farmacologia , Resultado do Tratamento , Adulto Jovem
Crit Care ; 15(1): R2, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21208418


INTRODUCTION: The relationship between isolated traumatic brain injury (TBI) associated coagulopathy and patient prognosis frequently lacks information regarding the time course of coagulation disorders throughout the post-traumatic period. This study was conducted to assess the prevalence and time course of post-traumatic coagulopathy in patients with isolated TBI and the relationship of these hemostatic disorders with outcome. METHODS: The local Human Subjects Committee approved the study. We retrospectively studied the medical records of computed tomography (CT)-confirmed isolated TBI patients with an extracranial abbreviated injury scale (AIS) <3 who were primarily referred to a Level 1 trauma centre in Amsterdam (n = 107). Hemostatic parameters including activated partial thromboplastin time (aPTT), prothrombin time (PT), platelet count, hemoglobin, hematocrit, glucose, pH and lactate levels were recorded throughout a 72-hour period as part of a routine standardized follow-up of TBI. Coagulopathy was defined as a aPPT >40 seconds and/or a PTT in International Normalized Ratio (INR) >1.2 and/or a platelet count <120*109/l. RESULTS: Patients were mostly male, aged 48 ± 20 years with a median injury severity score of 25 (range 20 to 25). Early coagulopathy as diagnosed in the emergency department (ED) occurred in 24% of all patients. The occurrence of TBI-related coagulopathy increased to 54% in the first 24 hours post-trauma. In addition to an increased age and disturbed pupillary reflex, both coagulopathy upon ED arrival and during the first 24 hours post-trauma provided an independent prognostic factor for unfavorable outcome (odds ratio (OR) 3.75 (95% CI 1.07 to 12.51; P = 0.04) and OR 11.61 (2.79 to 48.34); P = 0.003). CONCLUSIONS: Our study confirms a high prevalence of early and delayed coagulopathy in patients with isolated TBI, which is strongly associated with an unfavorable outcome. These data support close monitoring of hemostasis after TBI and indicate that correction of coagulation disturbances might need to be considered.

Transtornos da Coagulação Sanguínea/epidemiologia , Lesões Encefálicas/sangue , Lesões Encefálicas/complicações , Doença Aguda , Adulto , Idoso , Transtornos da Coagulação Sanguínea/terapia , Lesões Encefálicas/terapia , Serviço Hospitalar de Emergência , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Prognóstico , Tempo de Protrombina , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
J ECT ; 27(3): 189-91, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21206372


OBJECTIVES: Rapid parasympathetic and sympathetic hemodynamic effects during electroconvulsive therapy (ECT) may pose vulnerable patients to significant risk for cardiovascular complications. Here, we evaluated the clinical feasibility of noninvasive beat-to-beat arterial blood pressure (BP) measurements in patients undergoing ECT. METHODS: Beat-to-beat hemodynamic effects were measured with a noninvasive BP monitor in 24 individual patients undergoing ECT during general anesthesia. Heart rate, systolic (SBP), and diastolic BP (DBP) as well as cardiac output (CO) were measured continuously. A significant increase in pulse rate and/or BP was treated with intermittent administration of esmolol and ketanserin. Data are presented as mean ± SD. RESULTS: The ECT stimulus induced a transient drop in BP and pulse rate, followed by a sharp rise in both parameters. The parasympathetic phase lasted 17 ± 9 seconds and was characterized by a drop in heart rate from 89 ± 15 to 42 ± 24 beats per minute, in SBP from 143 ± 22 to 91 ± 31 mm Hg, in DBP from 82 ± 13 to 54 ± 22 mm Hg, and in CO from 5.7 ± 2.3 to 1.4 ± 1.0 L/min, respectively. During the subsequent sympathetic phase, the heart rate increased to 125 ± 26 beats per minute, the SBP to 192 ± 33 mm Hg, the DBP to 113 ± 21 mm Hg, and the CO to 7.4 ± 4.3 L/min. The time interval between the lowest and highest SBP was 60 ± 48 seconds. CONCLUSIONS: Noninvasive beat-to-beat BP measurements are feasible during ECT and may be used to guide rapid therapeutic interventions during ECT-induced hemodynamic effects.

Hemodinâmica/fisiologia , Monitorização Fisiológica/métodos , Adolescente , Antagonistas Adrenérgicos beta/uso terapêutico , Adulto , Idoso , Anestesia Geral , Pressão Sanguínea/fisiologia , Débito Cardíaco/fisiologia , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/epidemiologia , Interpretação Estatística de Dados , Eletrocardiografia , Eletroconvulsoterapia/efeitos adversos , Feminino , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Sistema Nervoso Parassimpático/fisiopatologia , Propanolaminas/uso terapêutico , Estudos Prospectivos , Risco , Volume Sistólico/fisiologia , Sistema Nervoso Simpático/fisiopatologia , Adulto Jovem