The role of viscoelastic testing in the management of the parturient.

Viscoelastic testing is the measurement of how the viscoelastic properties of blood change as blood clots. In pregnancy, unique changes in clotting function occur overall to make the pregnant woman hypercoagulable. Viscoelastic testing may be able to play a role in guiding placement of epidural and spinal anesthetics by demonstrating enhanced coagulation function, even when there are individual parts of the coagulation system that are abnormal, for example, thrombocytopenia. These tools may also play a role in addressing the management of maternal hemorrhage, which in the United States is on the rise. This review discusses the opportunity to use viscoelastic testing in the parturient.

Torticollis in a haemophilic infant with inhibitor: a case of spinal epidural haematoma.

Central nervous system bleeding, which can be a life-threatening complication, is seen in 2.7% of patients with haemophilia. Spinal epidural haematomas represent about one-tenth of such cases. Here, we report on a 10-month-old boy with severe haemophilia A, who presented with torticollis. Although administration of factor VIII at a dose of 50 U/kg, the patient developed flaccid paralysis of the upper extremities. Factor VIII inhibitor screen was positive. Magnetic resonance imaging of the spine revealed spinal epidural haematomas, extending from C-1 to the cauda equina. Treatment was continued with recombinant activated factor VIIa without surgery. After 1 month, complete neurological recovery was achieved and fully resolved haematomas were detected on spinal MRI. A prompt radiological evaluation of the cervical spine with MRI should be made in patients with haemophilia presenting with torticollis. In addition, in the case of life-threatening bleeding in patients with haemophilia, the possibility of an inhibitor should be kept in mind.

New anticoagulants: perioperative considerations.

During preoperative patient evaluation, anaesthesiologists assess the patient's bleeding history and risks for thrombosis and initiate individualized coagulation management. New potent anticoagulants may increase blood loss and the risk for spinal haematoma in patients scheduled for neuraxial anaesthesia. Postoperative start of thromboprophylaxis and recommendations on the timing of invasive interventions help in controlling these risks. Before widespread use for cardiological indications open questions need to be answered e.g. oral drug administration in postoperative vomiting and potential interactions with postoperative pain therapy.

Expanding perfusion across disciplines: the use of thrombelastography technology to reduce risk in an obstetrics patient with Gray Platelet Syndrome--a case study.

It is important that our speciality continues to push its boundaries. Our perfusion team has invested time lecturing to non-cardiac specialties about perfusion-led technology. This resulted in working closely with the obstetrics team to treat a pregnant patient with the bleeding disorder Gray Platelet Syndrome. In the first instance, we used our Thromboelastograph (TEG) platelet mapping programme to assess the patient. These results agreed with the platelet aggregation tests, showing a degree of platelet inhibition, but it was the overall clotting profile (basic thrombelastograph), showing a borderline hyper-coagulable state, that was of most interest and commonly seen in pregnancy. We believe a TEG result within acceptable limits could help re-adjust the risk of spinal haematomas following regional anaesthesia, thereby, reducing the risks of difficult intubation and general anaesthetic exposure to the baby. The case study describes both basic and platelet mapping thrombelastographs and their potential role in not only this patient with Gray Platelet Syndrome, but any obstetric patient where there are bleeding concerns.

Spinal anterior epidural hematoma in an elderly man with unrecognized lupic anticoagulant taking warfarin.

Spinal epidural hematoma (SEH) is a rare acute condition defined as a hematoma occurring at spinal epidural level. It is defined as "spontaneous" (SSEH) when possible causes have been ruled out; in other cases, clotting disorders and systemic lupus erythematosus have been associated with SEH. If identified rapidly, SEH can be completely cured, with complete recovery in about 50% of cases. We describe the case of an 86-year-old man affected by SEH, with rare anterior location, presenting with painful paraparesis and bladder dysfunction. The patient was taking warfarin for chronic atrial fibrillation. A prolongation of partial thromboplastin time was observed, consistent with the presence, in plasma, of previously unrecognized lupus anticoagulant antibodies (LA). The diagnosis of SEH was confirmed by MRI, and the patient was not surgically treated. Following a rehabilitation program, the patient had complete neurological recovery. Although the epidural lesion might have been a true case of SSEH, anticoagulation therapy and AL may have played a role in the pathogenesis, spread and spontaneous resolution of SEH. In cases of acute thoracic pain, associated with signs and symptoms of spinal cord compression, the diagnosis of SEH, which is a potentially devastating condition, must be carefully investigated by clinicians.

Conservative management of an acute spontaneous holocord epidural hemorrhage in a hemophiliac infant.

Central nervous system hemorrhages are an uncommon but severe complication of hemophilia, occurring in only 2-8% of children with hemophilia. Less than 10% of these CNS hemorrhages are intraspinal. The authors report on their care of an infant with hemophilia A who presented with irritability, meningismus, and decreased spontaneous movement. These symptoms prompted imaging studies, which revealed a spinal epidural hematoma (SEH) extending from C-1 through the cauda equina. The boy was treated with factor replacement and close monitoring. Repeat radiographic imaging 14 days later demonstrated complete resolution, and the patient had returned to his normal baseline status. A literature review in the modern treatment era revealed 24 cases of SEH in children with hemophilia. Of these 24 cases, 11 underwent laminectomy and 13 received conservative treatment. All conservatively treated patients, 5 of whom had presented with weakness, experienced a full recovery. Of the 11 laminectomy patients, 10 presented with weakness and all but 3 experienced full neurological improvement. These 3 patients were notable for having previously undiagnosed hemophilia. An increased index of suspicion facilitates the essential management features of prompt diagnosis and correction of coagulopathies in children who present with SEHs. The authors apply a multidisciplinary approach involving a pediatric hematologist, neurosurgeon, and pediatric intensive care unit to ensure timely correction of the coagulation disorder, maintenance of adequate factor levels, and close hemodynamic and neurological monitoring. Observation with aggressive correction of coagulopathy is a reasonable treatment choice for hemophilic patients presenting with SEH and a stable neurological examination.