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1.
Orv Hetil ; 161(34): 1414-1422, 2020 08.
Artigo em Húngaro | MEDLINE | ID: mdl-32804671

RESUMO

INTRODUCTION: Bleeding and transfusions following cardiac surgery significantly increase the rate of complications. Early diagnosis of "surgical" and "coagulopathic" bleeding is a prerequisite for effective treatment. Thromboelastometry with targeted hemostasis therapy can help in setting up the indication for reoperation and reduction of blood loss, transfusions and costs. AIM: We aimed to develop a local "reoperation for bleeding" protocol derived from the data of our former patients. METHOD: Based on data from 1011 cardiac surgical patients (control group), we developed a statistical algorithm to distinguish between "coagulopathic" and "surgical" bleeding. We used viscoelastic coagulation test and risk stratification. In 112 consecutive patients (study group), we examined the reoperations, and the impact of the protocol on the rates of transfusions and treatment costs. RESULTS: There was no difference in the rate of reoperations between the two groups (6.2% vs. 5.4%; p = 0.584). No coagulopathic bleeding occurred in the study group, compared to 12.7% in the control group. In the study group, we experienced reduction in bleeding (p = 0.026), an increased application of fibrinogen (p<0.001), prothrombin complex concentrate (p<0.001), and tranexamic acid (p<0.001). Red blood cell transfusions decreased by 30% (1.7 ± 2.6 E vs. 2.3 ± 3.3 E; p = 0.012). No difference was found in the amounts of fresh frozen plasma or platelet transfusions used. Calculated cost savings were HUF -20,333 per patient. CONCLUSION: Using this algorithm, reoperations were performed only in cases of surgical bleeding. The amount of bleeding, requirement for transfusions and treatment costs were reduced. Orv Hetil. 2020; 161(34): 1414-1422.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Hemostasia Cirúrgica/métodos , Hemostáticos/uso terapêutico , Terapia de Alvo Molecular , Reoperação , Algoritmos , Estudos de Casos e Controles , Terapia Combinada , Humanos , Resultado do Tratamento
2.
Am J Nurs ; 120(9): 36-43, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32858696

RESUMO

Optimal management of trauma-related hemorrhagic shock begins at the point of injury and continues throughout all hospital settings. Several procedures developed on the battlefield to treat this condition have been adopted by civilian health care systems and are now used in a number of nonmilitary hospitals. Despite the important role nurses play in caring for patients with trauma-related hemorrhagic shock, much of the literature on this condition is directed toward paramedics and physicians. This article discusses the general principles underlying the pathophysiology and clinical management of trauma-related hemorrhagic shock and updates readers on nursing practices used in its management.


Assuntos
Serviços Médicos de Emergência/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Choque Hemorrágico/terapia , Centros de Traumatologia/organização & administração , Hemorragia/terapia , Hemostáticos/uso terapêutico , Humanos , Traumatismo Múltiplo/complicações , Choque Hemorrágico/enfermagem , Gestão da Qualidade Total
4.
Medicine (Baltimore) ; 99(20): e20284, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32443373

RESUMO

INTRODUCTION: Alveolar hemorrhage (AH) is characterized by the acute onset of alveolar bleeding and hypoxemia and can be fatal. Thrombin has been widely used to achieve coagulation and hemostasis. However, the efficacy of thrombin in patients with AH is unclear. Thus, this study aimed to evaluate the efficacy of thrombin administration in patients with hematological malignancy and AH. PATIENT CONCERNS AND DIAGNOSES: This retrospective study included 15 hematological malignancy patients (8 men and 7 women; mean age 47.7 ±â€Š17.3 years) with AH who were administered intrapulmonary thrombin between March 2013 and July 2018. INTERVENTIONS AND OUTCOMES: All patients received bovine-origin thrombin (1000 IU/ml, Reyon Pharmaceutical Co., Ltd., Seoul, Korea) via a fiberoptic bronchoscope. A maximum of 15 ml of thrombin was injected via the working channel to control bleeding. The ability of thrombin to control bleeding was assessed. Additionally, the change in the PaO2/FiO2 (PF) ratio after intrapulmonary thrombin administration was evaluated. Intrapulmonary thrombin was administered a minimum of 3 days after starting mechanical ventilation in all patients, and it immediately controlled the active bleeding in 13 of 15 patients (86.7%). However, AH relapse was noted in 3 of the 13 patients (23.1%). The PF ratio improved in 10 of 15 patients (66.6%), and the mean PF ratio was significantly higher after thrombin administration than before administration (P = .03). No adverse thromboembolic complications or systemic adverse events were observed. CONCLUSION: Thrombin administration was effective in controlling bleeding in hematological malignancy patients with AH. Intrapulmonary thrombin administration might be a good therapeutic option for treating AH.


Assuntos
Neoplasias Hematológicas/complicações , Hemorragia/tratamento farmacológico , Hemostáticos/uso terapêutico , Pneumopatias/tratamento farmacológico , Trombina/uso terapêutico , Adolescente , Adulto , Idoso , Feminino , Hemorragia/etiologia , Hemostáticos/administração & dosagem , Humanos , Pneumopatias/etiologia , Masculino , Pessoa de Meia-Idade , Alvéolos Pulmonares/patologia , Estudos Retrospectivos , Trombina/administração & dosagem , Adulto Jovem
6.
Arterioscler Thromb Vasc Biol ; 40(5): 1148-1154, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32237902

RESUMO

Emicizumab is a humanized anti-FIXa/FX (factor IXa/X) bispecific monoclonal antibody that mimics FVIIIa (activated factor VIII) cofactor function. The hemostatic efficacy of emicizumab has been confirmed in clinical studies of patients with hemophilia A, irrespective of the presence of FVIII inhibitors. Emicizumab differs in some properties from FVIIIa molecule. Emicizumab requires no activation by thrombin and is not inactivated by activated protein C, but emicizumab-mediated coagulation is regulatable and maintains hemostasis. A small amount of FIXa (activated factor IX) is required to initiate emicizumab-mediated hemostasis, whereas tissue factor/FVIIa (activated factor VII)-mediated FXa (activated factor X) and thrombin activation initiates FVIIIa-mediated hemostasis. Fibrin formation, followed by fibrinolysis, appears to be similar between emicizumab- and FVIIIa-mediated hemostasis. These results suggest possible future uses of emicizumab for treating hemorrhagic diseases other than hemophilia A and reveal previously unobservable behaviors of procoagulation and anticoagulation factors in conventional hemostasis. Here, we have reviewed novel insights and new developments regarding coagulation highlighted by emicizumab.


Assuntos
Anticorpos Biespecíficos/uso terapêutico , Anticorpos Monoclonais Humanizados/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Hemofilia A/tratamento farmacológico , Hemostáticos/uso terapêutico , Animais , Anticorpos Biespecíficos/efeitos adversos , Anticorpos Monoclonais Humanizados/efeitos adversos , Hemofilia A/sangue , Hemofilia A/diagnóstico , Hemostáticos/efeitos adversos , Humanos , Fatores de Risco , Resultado do Tratamento
7.
Transfusion ; 60(5): 897-907, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32319687

RESUMO

In the United States, postpartum hemorrhage (PPH) accounts for 4.6% of all maternal deaths and is responsible for major peripartum medical and surgical morbidity. Therefore, a national health priority is to ensure that women who experience severe PPH receive timely, appropriate, and effective treatment. In this article, we describe our system-wide approach for the planning and delivery of women with suspected placenta accreta spectrum disorder, a condition associated with life-threatening blood loss at the time of delivery. We also highlight current evidence related to transfusion decision making and hemostatic monitoring during active postpartum bleeding. Specifically, we describe how we activate and use the massive transfusion protocol to obtain sufficient volumes and types of blood products. We also describe how we use viscoelastic monitoring (thromboelastography) and standard laboratory tests to assess the maternal coagulation profile. Finally, we review the findings of recent studies examining the potential efficacy of tranexamic acid and fibrinogen concentrate as adjuncts for PPH prevention and treatment. We describe how we have incorporated these drugs into PPH treatment protocols at our institution.


Assuntos
Hemorragia Pós-Parto/terapia , Testes de Coagulação Sanguínea , Transfusão de Sangue/métodos , Transfusão de Sangue/normas , Feminino , Hemostáticos/uso terapêutico , Humanos , Monitorização Fisiológica/métodos , Monitorização Fisiológica/normas , Período Pós-Parto , Gravidez , Fatores de Risco , Índice de Gravidade de Doença , Tromboelastografia
8.
Int J Clin Pharmacol Ther ; 58(6): 351-353, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32194023

RESUMO

Hemocoagulase is often used for hemostasis in patients with bleeding and hemorrhagic diseases, and to avoid or stanch bleeding after surgery. Herein, three patients with hepatic diseases suffering from hypofibrinogenemia were treated with hemocoagulase agkistrodon (HCA) in Peking University People's Hospital during September 2018. All the 3 patients were chronic hepatitis B patients: Patient 1 presented with hepatic carcinoma and chronic hepatitis B, and right hepatectomy was performed; patient 2 presented with chronic hepatitis B and gastrointestinal bleeding; patient 3 presented with chronic hepatitis B, acute liver failure with hematemesis, and was awaiting liver transplantation. All three patients were percutaneously injected with HCA to prevent late-onset bleeding. After HCA was discontinued, coagulation was restored to > 60 mg/dL on day 6, without injection of fibrinogen. HCA significantly reduced the need for fibrinogen in patients with hepatic diseases, and the level of fibrinogen should be carefully monitored in clinical applications.


Assuntos
Afibrinogenemia , Agkistrodon , Batroxobina/uso terapêutico , Hemostáticos/uso terapêutico , Hepatopatias/tratamento farmacológico , Animais , Fibrinogênio , Humanos
9.
J Biol Regul Homeost Agents ; 34(1 Suppl. 1): 109-113, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32064843

RESUMO

Control of bleeding after oral surgery is mandatory in patients taking anticoagulants. There are different haemostatic measures to prevent post-surgical bleeding. The aim of the present paper is to study the use of a haemostatic agent, calcium sulphate (CaS) (P30, Ghimas, Bologna, Italy) for controlling post-surgical bleeding in a group of patients treated with warfarin therapy for thromboembolic states. Twenty teeth (12 mandibular molars, 8 maxillary molars) in 20 patients (14 male and 6 females) with a mean age of 54.3 years (±10.3 years) were included in the study. The patients were divided into 2 groups; in the study group of 10 patients calcium sulphate was used in layers to fill the socket after extraction, while for the 10 patients in the control group put a gauze with tranexamic acid was put in the extraction site immediately after extraction, and half an hour after extraction. The outcome was bleeding in subsequent days. Bleeding at post-operative day 1 was significant in 5 patients of the control group, however, in the study group treated with calcium sulfate there was no bleeding in any patient (p value 0.0055). CaS demonstrated to be a good haemostatic agent for controlling bleeding after oral surgery in patients taking anticoagulants.


Assuntos
Sulfato de Cálcio/uso terapêutico , Hemostáticos/uso terapêutico , Hemorragia Pós-Operatória/tratamento farmacológico , Extração Dentária , Administração Oral , Adulto , Anticoagulantes/uso terapêutico , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
10.
Crit Care ; 24(1): 19, 2020 01 20.
Artigo em Inglês | MEDLINE | ID: mdl-31959232

RESUMO

During extracorporeal membrane oxygenation (ECMO), a delicate balance is required to titrate systemic anticoagulation to prevent thrombotic complications within the circuit and prevent bleeding in the patient. Despite focused efforts to achieve this balance, the frequency of both thrombotic and bleeding events remains high. Anticoagulation is complicated to manage in this population due to the complexities of the hemostatic system that are compounded by age-related developmental hemostatic changes, variable effects of the etiology of critical illness on hemostasis, and blood-circuit interaction. Lack of high-quality data to guide anticoagulation management in ECMO patients results in marked practice variability among centers. One aspect of anticoagulation therapy that is particularly challenging is the use of antithrombin (AT) supplementation for heparin resistance. This is especially controversial in the neonatal and pediatric population due to the baseline higher risk of bleeding in this cohort. The indication for AT supplementation is further compounded by the potential inaccuracy of the diagnosis of heparin resistance based on the standard laboratory parameters used to assess heparin effect. With concerns regarding the adverse impact of bleeding and thrombosis, clinicians and institutions are faced with making difficult, real-time decisions aimed at optimizing anticoagulation in this setting. In this clinically focused review, the authors discuss the complexities of anticoagulation monitoring and therapeutic intervention for patients on ECMO and examine the challenges surrounding AT supplementation given both the historical and current perspectives summarized in the literature on these topics.


Assuntos
Anticoagulantes/análise , Antitrombinas/uso terapêutico , Oxigenação por Membrana Extracorpórea/métodos , Monitorização Fisiológica/normas , Anticoagulantes/sangue , Antitrombinas/normas , Coagulação Sanguínea/efeitos dos fármacos , Criança , Inibidores do Fator Xa/farmacologia , Inibidores do Fator Xa/uso terapêutico , Feminino , Hemostáticos/uso terapêutico , Humanos , Masculino , Monitorização Fisiológica/métodos , Monitorização Fisiológica/tendências , Tempo de Tromboplastina Parcial/métodos , Tempo de Coagulação do Sangue Total/métodos
11.
Otolaryngol Head Neck Surg ; 162(1_suppl): S1-S38, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31910111

RESUMO

OBJECTIVE: Nosebleed, also known as epistaxis, is a common problem that occurs at some point in at least 60% of people in the United States. While the majority of nosebleeds are limited in severity and duration, about 6% of people who experience nosebleeds will seek medical attention. For the purposes of this guideline, we define the target patient with a nosebleed as a patient with bleeding from the nostril, nasal cavity, or nasopharynx that is sufficient to warrant medical advice or care. This includes bleeding that is severe, persistent, and/or recurrent, as well as bleeding that impacts a patient's quality of life. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds. PURPOSE: The primary purpose of this multidisciplinary guideline is to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds. The target patient for the guideline is any individual aged ≥3 years with a nosebleed or history of nosebleed who needs medical treatment or seeks medical advice. The target audience of this guideline is clinicians who evaluate and treat patients with nosebleed. This includes primary care providers such as family medicine physicians, internists, pediatricians, physician assistants, and nurse practitioners. It also includes specialists such as emergency medicine providers, otolaryngologists, interventional radiologists/neuroradiologists and neurointerventionalists, hematologists, and cardiologists. The setting for this guideline includes any site of evaluation and treatment for a patient with nosebleed, including ambulatory medical sites, the emergency department, the inpatient hospital, and even remote outpatient encounters with phone calls and telemedicine. Outcomes to be considered for patients with nosebleed include control of acute bleeding, prevention of recurrent episodes of nasal bleeding, complications of treatment modalities, and accuracy of diagnostic measures. This guideline addresses the diagnosis, treatment, and prevention of nosebleed. It focuses on nosebleeds that commonly present to clinicians via phone calls, office visits, and emergency room encounters. This guideline discusses first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery. It also addresses more complex epistaxis management, which includes the use of endoscopic arterial ligation and interventional radiology procedures. Management options for 2 special groups of patients-patients with hereditary hemorrhagic telangiectasia syndrome and patients taking medications that inhibit coagulation and/or platelet function-are included in this guideline. This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not intended to be a comprehensive, general guide for managing patients with nosebleed. In this context, the purpose is to define useful actions for clinicians, generalists, and specialists from a variety of disciplines to improve quality of care. Conversely, the statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experience and assessment of individual patients. ACTION STATEMENTS: The guideline development group made recommendations for the following key action statements: (1) At the time of initial contact, the clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not. (2) The clinician should treat active bleeding for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer. (3a) For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packing. (3b) The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications. (4) The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment. (5) The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. (6) The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot (if present) for patients with nosebleeds. (7a) The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. (8) The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. (9) When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding. (10) The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. (11) In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications for patients using these medications. (12) The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. (13) The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. (14) The clinician or designee should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with nonresorbable packing, surgery, or arterial ligation/embolization. The policy level for the following recommendation, about examination of the nasal cavity and nasopharynx using nasal endoscopy, was an option: (7b) The clinician may perform, or may refer to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis.


Assuntos
Cauterização , Endoscopia/métodos , Epistaxe/terapia , Ligadura , Melhoria de Qualidade , Vasoconstritores/uso terapêutico , Epistaxe/diagnóstico , Epistaxe/prevenção & controle , Hemostáticos/uso terapêutico , Humanos , Procedimentos Cirúrgicos Nasais/métodos , Gravidade do Paciente , Educação de Pacientes como Assunto/métodos , Fatores de Risco , Tampões Cirúrgicos , Telangiectasia Hemorrágica Hereditária/diagnóstico
12.
Obstet Gynecol ; 135(2): 463-468, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31923069

RESUMO

Since a variety of procoagulant products, collectively called hemostatic agents, became available to surgeons in the mid-20th century, their use has increased across multiple specialties, including gynecology. Congruent with past research on the causes of regional variation in the practice of medicine, available evidence suggests that a central predictor for use of these products is physician preference rather than documented clinical necessity. Use of these products adds risks and avoidable cost. This article seeks to highlight specific gynecologic circumstances in which evidence and surgical judgment supports hemostatic agent use and other settings in which use should be reconsidered.


Assuntos
Adesivo Tecidual de Fibrina/uso terapêutico , Procedimentos Cirúrgicos em Ginecologia , Hemostáticos/uso terapêutico , Procedimentos Cirúrgicos Minimamente Invasivos , Administração Tópica , Perda Sanguínea Cirúrgica , Feminino , Adesivo Tecidual de Fibrina/efeitos adversos , Adesivo Tecidual de Fibrina/economia , Hemostáticos/efeitos adversos , Hemostáticos/economia , Humanos , Duração da Cirurgia , Medição de Risco
13.
Carbohydr Polym ; 230: 115585, 2020 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-31887971

RESUMO

The application of hemostatic agents is essential to prevent significant blood loss and death from excessive bleeding in surgical or emergency scenarios. Oxidized cellulose is an excellent biodegradable and biocompatible derivate of cellulose, which has become one of the most important hemostatic agents used in surgical procedures. However, to date, there has been no comprehensive report assessing oxidized cellulose-based hemostatic materials. Hence, this paper first reviewed the oxidation preparation, cellulose origin and structure, as well as biodegradability and safety of oxidized cellulose. Then a comprehensive review regarding the hemostatic mechanisms, various forms, modification, and current commercially available products of oxidized cellulose is discussed, which emphatically presents the most significant developments in the recent scientific literature. In conclusion, this paper summarizes the latest developments in oxidized cellulose-based hemostatic materials and provides a reference for further research and development in this field.


Assuntos
Celulose Oxidada/química , Hemorragia/tratamento farmacológico , Hemostáticos/uso terapêutico , Celulose/química , Celulose Oxidada/uso terapêutico , Hemostasia/efeitos dos fármacos , Hemostáticos/química , Humanos , Oxirredução/efeitos dos fármacos
14.
Vet Surg ; 49(4): 758-763, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31916606

RESUMO

OBJECTIVE: To document marked hemorrhage as a complication of inguinal cryptorchidectomy and its successful treatment with a novel chitosan-based hemostatic agent. STUDY DESIGN: Case report. ANIMALS: One healthy 5-year old quarter horse cryptorchid. METHODS: The horse was presented for routine unilateral cryptorchidectomy after prior hemicastration. An inguinal approach was made to the abdomen, and the right external pudendal artery was lacerated at the level of the internal inguinal ring, requiring multiple anesthetic events over a 2-week period in attempts to control hemorrhage. A chitosan-based hemostatic agent was packed into the wound to gain control. RESULTS: Chitosan granules placed in the wound successfully controlled the hemorrhage, whereas the use of gauze packing alone failed. There were no immediate or long-term complications to the chitosan granules; the horse was doing well 18 months postoperatively, and the client was satisfied with the outcome. CONCLUSION: Major hemorrhage was demonstrated from the external pudendal artery and caused difficulties because it occurred deep within the inguinal canal during an inguinal cryptorchidectomy. A chitosan-based hemostatic agent was successfully used to achieve hemostasis. CLINICAL SIGNIFICANCE: The external pudendal artery should be avoided in the medial commissure of the inguinal canal. The use of chitosan-based hemostatic agents warrants further investigation in horses because these products may be useful for controlling major hemorrhage from various causes in equine practice.


Assuntos
Quitosana/uso terapêutico , Criptorquidismo/veterinária , Hemostasia , Hemostáticos/uso terapêutico , Doenças dos Cavalos/cirurgia , Animais , Criptorquidismo/sangue , Criptorquidismo/cirurgia , Doenças dos Cavalos/sangue , Cavalos , Masculino
15.
Knee ; 27(1): 229-234, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31882387

RESUMO

BACKGROUND: Antifibrinolytic drugs are widely used to minimize blood loss and transfusion requirements in total knee arthroplasty (TKA). Although tranexamic acid (TXA) has been widely studied for its use in TKA, there are limited studies on epsilon-aminocaproic acid (EACA). METHODS: In a double-blind randomized control trial, all patients (n = 91) operated with bilateral simultaneous TKA were randomly given either intravenous EACA or placebo (normal saline). A single surgeon performed the TKA with posterior-stabilized implants under tourniquet. A suction drain was placed and kept for 48 h postoperatively. The intraoperative blood loss and drain output were calculated. The postoperative hemoglobin (Hb), drop in Hb, total blood loss, and number of blood transfusions in each group were calculated. RESULTS: Both of the groups were comparable in terms of age, sex, body mass index, and pre-operative Hb. There was a significant difference between the EACA group and control group in terms of intraoperative blood loss (150 ml vs. 165 ml, P = 0.01), drain output (494 ml vs. 1062 ml, P < 0.001), postoperative Hb (9.9 g/dl vs. 8.6 g/dl, P = 0.002), drop in Hb (2.2 g/dl vs. 3.1 g/dl, P = 0.026) and transfusion rate (median transfusion 0 vs. 1, P < 0.001). The total blood loss, as calculated by the Hb balance method, was significantly less (P < 0.001) in the EACA group (0.99 l) compared with the control group (2.71 l). None of the patients developed any adverse reaction/complication to the drug. CONCLUSION: Intraoperative administration of EACA significantly decreased the blood loss and postoperative transfusion rates compared with no antifibrinolytic therapy in bilateral simultaneous TKA.


Assuntos
Ácido Aminocaproico/uso terapêutico , Antifibrinolíticos/uso terapêutico , Artroplastia do Joelho/métodos , Perda Sanguínea Cirúrgica/prevenção & controle , Hemostáticos/uso terapêutico , Hemorragia Pós-Operatória/prevenção & controle , Administração Intravenosa , Idoso , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/instrumentação , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/etiologia , Torniquetes
16.
Am J Emerg Med ; 38(4): 810-814, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31870672

RESUMO

OBJECTIVE: In 2018, the FDA approved andexanet alfa for the reversal of life-threatening hemorrhages in patients anticoagulated with apixaban or rivaroxaban. Yet, cost-effective factor Xa inhibitor reversal remains controversial. The objective of this study was to describe real world utilization of andexanet alfa. METHODS: This was a retrospective case series of patients receiving andexanet alfa between July 28, 2018 and April 29, 2019 at a large academic health system. Baseline demographics, anticoagulant type and reversal, as well as brain imaging were collected. Primary endpoints were stability of hematoma for intracranial hemorrhage (ICH), and hemostatic effectiveness for patients undergoing surgical procedures. Secondary endpoints were thromboembolism and 30 day mortality. RESULTS: Of the 25 patients evaluated, 13 received andexanet alfa for ICH. Eleven of the 13 had follow-up imaging available and stability was observed in 90.9%. Three patients received andexanet alfa for reversal prior to surgical procedures, and 100% hemostatic effectiveness was achieved. Nine patients received andexanet alfa for reversal of extracranial bleeding, including gastrointestinal bleed (n=4). There were no thrombotic events in our cohort, and 30 day mortality was 24%. Sixty-four percent of patients would have met exclusion criteria for the ANNEXA-4 trial. CONCLUSION: This is the largest series to date describing real-world utilization of andexanet alfa. Our series showed hemostatic efficacy in 90.9% of patients with ICH, and 100% in patients undergoing surgical procedures. There were no thrombotic complications. Yet, larger and comparative studies are needed to clarify the optimal agent and patient selection for reversal of factor Xa inhibitors.


Assuntos
Fator Xa/uso terapêutico , Hemorragia/tratamento farmacológico , Hemostáticos/uso terapêutico , Proteínas Recombinantes/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/tratamento farmacológico , Hemorragia/induzido quimicamente , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Pirazóis/efeitos adversos , Pirazóis/antagonistas & inibidores , Piridonas/efeitos adversos , Piridonas/antagonistas & inibidores , Estudos Retrospectivos , Rivaroxabana/efeitos adversos , Rivaroxabana/antagonistas & inibidores , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do Tratamento
17.
Medicine (Baltimore) ; 98(52): e18534, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31876750

RESUMO

BACKGROUND: Hemocoagulase is isolated and purified from snake venoms. Hemocoagulase agents have been widely used in the prevention and treatment of surgical bleeding. A systematic review was performed to evaluate the effects of hemocoagulase on postoperative bleeding and transfusion in patients who underwent cardiac surgery. METHODS: Electronic databases were searched to identify all clinical trials comparing hemocoagulase with placebo/blank on postoperative bleeding and transfusion in patients undergoing cardiac surgery. Two authors independently extracted perioperative data and outcome data. For continuous variables, treatment effects were calculated as weighted mean difference and 95% confidential interval (CI). For dichotomous data, treatment effects were calculated as odds ratio and 95% CI. Each outcome was tested for heterogeneity, and randomized-effects or fixed-effects model was used in the presence or absence of significant heterogeneity. Sensitivity analyses were done by examining the influence of statistical model and individual trial on estimated treatment effects. Publication bias was explored through visual inspection of funnel plots of the outcomes. Statistical significance was defined as P < .05. RESULTS: Our search yielded 12 studies including 900 patients, and 510 patients were allocated into hemocoagulase group and 390 into control group. Meta-analysis suggested that, hemocoagulase-treated patients had less bleeding volume, reduced red blood cells and fresh frozen plasma transfusion, and higher hemoglobin level than those of controlled patients postoperatively. Meta-analysis also showed that, hemocoagulase did not influence intraoperative heparin or protamine dosages and postoperative platelet counts. Meta-analysis demonstrated that, hemocoagulase-treated patients had significantly shorter postoperative prothrombin time, activated partial thromboplastin time, and thrombin time, higher fibrinogen level and similar D-dimer level when compared to control patients. CONCLUSION: This meta-analysis has found some evidence showing that hemocoagulase reduces postoperative bleeding, and blood transfusion requirement in patients undergoing cardiac surgery. However, these findings should be interpreted rigorously. Further well-conducted trials are required to assess the blood-saving effects and mechanisms of Hemocoagulase.


Assuntos
Batroxobina/uso terapêutico , Transfusão de Sangue/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos/métodos , Hemostáticos/uso terapêutico , Hemorragia Pós-Operatória/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Humanos
18.
Cochrane Database Syst Rev ; 11: CD012745, 2019 11 28.
Artigo em Inglês | MEDLINE | ID: mdl-31778223

RESUMO

BACKGROUND: In the absence of bleeding, plasma is commonly transfused to people prophylactically to prevent bleeding. In this context, it is transfused before operative or invasive procedures (such as liver biopsy or chest drainage tube insertion) in those considered at increased risk of bleeding, typically defined by abnormalities of laboratory tests of coagulation. As plasma contains procoagulant factors, plasma transfusion may reduce perioperative bleeding risk. This outcome has clinical importance given that perioperative bleeding and blood transfusion have been associated with increased morbidity and mortality. Plasma is expensive, and some countries have experienced issues with blood product shortages, donor pool reliability, and incomplete screening for transmissible infections. Thus, although the benefit of prophylactic plasma transfusion has not been well established, plasma transfusion does carry potentially life-threatening risks. OBJECTIVES: To determine the clinical effectiveness and safety of prophylactic plasma transfusion for people with coagulation test abnormalities (in the absence of inherited bleeding disorders or use of anticoagulant medication) requiring non-cardiac surgery or invasive procedures. SEARCH METHODS: We searched for randomised controlled trials (RCTs), without language or publication status restrictions in: Cochrane Central Register of Controlled Trials (CENTRAL; 2017 Issue 7); Ovid MEDLINE (from 1946); Ovid Embase (from 1974); Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCOHost) (from 1937); PubMed (e-publications and in-process citations ahead of print only); Transfusion Evidence Library (from 1950); Latin American Caribbean Health Sciences Literature (LILACS) (from 1982); Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (Thomson Reuters, from 1990); ClinicalTrials.gov; and World Health Organization (WHO) International Clinical Trials Registry Search Platform (ICTRP) to 28 January 2019. SELECTION CRITERIA: We included RCTs comparing: prophylactic plasma transfusion to placebo, intravenous fluid, or no intervention; prophylactic plasma transfusion to alternative pro-haemostatic agents; or different haemostatic thresholds for prophylactic plasma transfusion. We included participants of any age, and we excluded trials incorporating individuals with previous active bleeding, with inherited bleeding disorders, or taking anticoagulant medication before enrolment. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included five trials in this review, all were conducted in high-income countries. Three additional trials are ongoing. One trial compared fresh frozen plasma (FFP) transfusion with no transfusion given. One trial compared FFP or platelet transfusion or both with neither FFP nor platelet transfusion given. One trial compared FFP transfusion with administration of alternative pro-haemostatic agents (factors II, IX, and X followed by VII). One trial compared the use of different transfusion triggers using the international normalised ratio measurement. One trial compared the use of a thromboelastographic-guided transfusion trigger using standard laboratory measurements of coagulation. Four trials enrolled only adults, whereas the fifth trial did not specify participant age. Four trials included only minor procedures that could be performed by the bedside. Only one trial included some participants undergoing major surgical operations. Two trials included only participants in intensive care. Two trials included only participants with liver disease. Three trials did not recruit sufficient participants to meet their pre-calculated sample size. Overall, the quality of evidence was low to very low across different outcomes according to GRADE methodology, due to risk of bias, indirectness, and imprecision. One trial was stopped after recruiting two participants, therefore this review's findings are based on the remaining four trials (234 participants). When plasma transfusion was compared with no transfusion given, we are very uncertain whether there was a difference in 30-day mortality (1 trial comparing FFP or platelet transfusion or both with neither FFP nor platelet transfusion, 72 participants; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.13 to 1.10; very low-quality evidence). We are very uncertain whether there was a difference in major bleeding within 24 hours (1 trial comparing FFP transfusion vs no transfusion, 76 participants; RR 0.33, 95% CI 0.01 to 7.93; very low-quality evidence; 1 trial comparing FFP or platelet transfusion or both with neither FFP nor platelet transfusion, 72 participants; RR 1.59, 95% CI 0.28 to 8.93; very low-quality evidence). We are very uncertain whether there was a difference in the number of blood product transfusions per person (1 trial, 76 participants; study authors reported no difference; very low-quality evidence) or in the number of people requiring transfusion (1 trial comparing FFP or platelet transfusion or both with neither FFP nor platelet transfusion, 72 participants; study authors reported no blood transfusion given; very low-quality evidence) or in the risk of transfusion-related adverse events (acute lung injury) (1 trial, 76 participants; study authors reported no difference; very low-quality evidence). When plasma transfusion was compared with other pro-haemostatic agents, we are very uncertain whether there was a difference in major bleeding (1 trial; 21 participants; no events; very low-quality evidence) or in transfusion-related adverse events (febrile or allergic reactions) (1 trial, 21 participants; RR 9.82, 95% CI 0.59 to 162.24; very low-quality evidence). When different triggers for FFP transfusion were compared, the number of people requiring transfusion may have been reduced (for overall blood products) when a thromboelastographic-guided transfusion trigger was compared with standard laboratory tests (1 trial, 60 participants; RR 0.18, 95% CI 0.08 to 0.39; low-quality evidence). We are very uncertain whether there was a difference in major bleeding (1 trial, 60 participants; RR 0.33, 95% CI 0.01 to 7.87; very low-quality evidence) or in transfusion-related adverse events (allergic reactions) (1 trial; 60 participants; RR 0.33, 95% CI 0.01 to 7.87; very low-quality evidence). Only one trial reported 30-day mortality. No trials reported procedure-related harmful events (excluding bleeding) or quality of life. AUTHORS' CONCLUSIONS: Review findings show uncertainty for the utility and safety of prophylactic FFP use. This is due to predominantly very low-quality evidence that is available for its use over a range of clinically important outcomes, together with lack of confidence in the wider applicability of study findings, given the paucity or absence of study data in settings such as major body cavity surgery, extensive soft tissue surgery, orthopaedic surgery, or neurosurgery. Therefore, from the limited RCT evidence, we can neither support nor oppose the use of prophylactic FFP in clinical practice.


Assuntos
Anticoagulantes/uso terapêutico , Transfusão de Componentes Sanguíneos/métodos , Hemorragia/prevenção & controle , Procedimentos Cirúrgicos Operatórios , Anticoagulantes/efeitos adversos , Hemostáticos/uso terapêutico , Humanos , Plasma , Cuidados Pré-Operatórios , Ensaios Clínicos Controlados Aleatórios como Assunto , Tromboelastografia
19.
Blood Coagul Fibrinolysis ; 30(8): 385-392, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31738288

RESUMO

: The novel agent pd-FVIIa/FX is a 1 : 10 protein weight mixture of activated factor VII (FVIIa) and factor X (FX) derived from donated blood plasma. A phase III clinical trial of pd-FVIIa/FX revealed high efficacy for bleeding episodes in haemophilia patients with inhibitors. However, up to now, only one case of this new agent being used for surgery had been reported. The objective of this study is to evaluate the perioperative haemostatic efficacy and safety of pd-FVIIa/FX in haemophilia patients with inhibitors. We retrospectively reviewed 25 operation charts from 14 haemophilia patients with high-responding inhibitors using pd-FVIIa/FX during the perioperative period. Efficacy was evaluated by attending physicians and results divided into four groups (excellent, good, fair, and poor). The operation chart was provided by nine Japanese medical institutes with expertise in haemophilia management. Out of the total of 25 surgical procedures, 44% (11/25) were classified as major surgery and the remainders were minor surgeries. In all of the surgeries but one, rFVIIa and/or APCC were administered in combination or sequential method. In all cases except one, the haemostatic efficiency rate was judged as excellent or good by treating physicians for an overall efficacy rate of 96%. No thrombotic adverse effects were reported. This study's results suggest that both combination and sequential therapy of pd-FVIIa/FX and other bypassing agents are well tolerated and effective for the control of perioperative bleeding in haemophilia patients with high-responding inhibitors.


Assuntos
Fator VIIa/uso terapêutico , Fator X/uso terapêutico , Hemofilia A/tratamento farmacológico , Hemofilia B/tratamento farmacológico , Hemostáticos/normas , Assistência Perioperatória/métodos , Adulto , Combinação de Medicamentos , Quimioterapia Combinada/efeitos adversos , Fator VIIa/efeitos adversos , Fator X/efeitos adversos , Hemofilia A/imunologia , Hemofilia B/imunologia , Hemorragia/prevenção & controle , Hemostáticos/efeitos adversos , Hemostáticos/uso terapêutico , Humanos , Masculino , Assistência Perioperatória/efeitos adversos , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Procedimentos Cirúrgicos Operatórios/normas , Trombose/induzido quimicamente , Resultado do Tratamento , Adulto Jovem
20.
United European Gastroenterol J ; 7(9): 1226-1233, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31700635

RESUMO

Background: A recent prospective randomised controlled trial ('STING') showed superiority of over-the-scope clips compared to standard treatment in recurrent peptic ulcer bleeding. Cost-effectiveness studies on haemostasis with over-the-scope clips have not been reported so far. Objective: The aim of this study was to investigate whether the higher efficacy of the over-the-scope clips treatment outweighs the higher costs of the device compared to standard clips. Methods: For the analysis, the study population of the STING trial was used. Costs for the hospital stay in total as well as treatment-related costs were obtained. The average cost-effectiveness ratio, representing the mean costs per designated outcome, and the incremental cost-effectiveness ratio, expressing the additional costs of a new treatment strategy per difference in outcome were calculated. The designated outcome was defined as successful haemostasis without rebleeding within seven days, which was the primary endpoint of the STING trial. Average cost-effectiveness ratio and incremental cost-effectiveness ratio were calculated for total costs of the hospital stay as well as the haemostasis treatment alone. The cost-effectiveness analysis is taken from the perspective of the care provider.Results: Total costs and treatment-related costs per patient were 13,007.07 € in the standard group vs 12,808.56 € in the over-the-scope clip group (p = 0.812) and 2084.98 € vs 1984.71 € respectively (p = 0.663). The difference was not statistically significant. Total costs per successful haemostasis (average cost-effectiveness ratio) were 30,677.05 € vs 15,104.43 € and 4917.41 € vs 2340.46 € for the haemostasis treatment. The additional costs per successful haemostasis with over-the-scope clip treatment (incremental cost-effectiveness ratio) is -468.18 € for the whole treatment and -236.49€ for the haemostasis treatment. Conclusions: Over-the-scope clip treatment is cost-effective in recurrent peptic ulcer bleeding.


Assuntos
Endoscopia do Sistema Digestório/economia , Hemostase Endoscópica/economia , Úlcera Péptica Hemorrágica/cirurgia , Instrumentos Cirúrgicos , Análise Custo-Benefício , Endoscopia do Sistema Digestório/métodos , Adesivo Tecidual de Fibrina/economia , Adesivo Tecidual de Fibrina/uso terapêutico , Hemostase Endoscópica/métodos , Hemostáticos/economia , Hemostáticos/uso terapêutico , Humanos , Recidiva
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