[Prophylactic use of tranexamic acid in noncardiac surgery : Update 2017]. / Prophylaktische Anwendung von Tranexamsäure in der nichtkardialen Chirurgie : Update 2017.

BACKGROUND: Minimising perioperative bleeding is a key goal of "patient blood management" programs. One component of respective strategies includes preventive inhibition of fibrinolysis using protease inhibitors, such as tranexamic acid (TXA). TXA inhibits plasminogen activation and plasmin-induced fibrin degradation. OBJECTIVES: The present article provides an overview of the existing literature and TXA applications in the prophylaxis of perioperative bleeding. METHODS: Literature search in PubMed/MEDLINE (U.S. National Library of Medicine®, Bethesda, MD, USA). RESULTS: TXA reduces perioperative blood loss and transfusion requirements in several randomized controlled trials (RCTs) and meta-analyses in the field of hip and knee arthroplasty for both intravenous and topical use. Moreover, evidence favours use of TXA in complex spine surgery and reconstructive surgery (e. g. craniosynostosis in children). Single RCTs showed benefits of TXA in abdominal hysterectomy, open prostatectomy, liver surgery and actively bleeding trauma patients. For prophylaxis of peripartum haemorrhage (PPH) following vaginal delivery or Caesarean section, TXA cannot be routinely recommended, although evidence points to benefits in actively bleeding patients. A recommendation exists for the treatment of (active) PPH. For prophylactic perioperative administration, different dosage regimens exist for adults. Most often an initial i. v. bolus of 1 g or 10-15 mg/kg body weight with/without repetition after 6 h or continuous infusions over 8 h is administered. Increased rates of thromboembolic events were not noted. CONCLUSION: Protease inhibitors such as TXA reduce perioperative blood loss and transfusion requirements in selected surgical fields.

[Association of tumor necrosis factor microsatellite polymorphism with incidence and outcome of severe postoperative sepsis].

OBJECTIVE: To investigate whether tumor necrosis factor (TNF) microsatellite polymorphism within the TNF locus is associated with the incidence and outcome of severe postoperative sepsis. METHODS: 122 patients with severe postoperative sepsis were included in this study; 138 local ethnically matched healthy individuals served as controls. Microsatellite TNFc polymorphism within the TNF locus was typed using polymerase chain reaction (PCR) followed by polyacrylamide gel electrophoresis with silver staining. RESULTS: Microsatellite TNFc polymorphism had two alleles (TNFc1 and TNFc2) and three kinds of genotype (homozygotes TNFc1c1 and TNFc2c2, and heterozygote TNFc1c2). The genotype distribution fit Hardy-Weinberg equilibrium. The frequency of TNFc1 microsatellite allele was significantly higher in patients with severe sepsis (79%) than in healthy individuals (71%) (P < 0.05). The frequency of heterozygote TNFc1c2 was significantly higher in non-surviving patients (46%) with severe sepsis than in survivors (27%) (P < 0.05). CONCLUSIONS: TNFc microsatellite polymorphism is significantly associated with the incidence and outcome of severe postoperative sepsis.

[Intensified therapy of severe lupus erythematosus]. / Intensivierte Therapie des schweren Lupus erythematodes.

14 female patients (mean age 28 [18-56] years) with severe systemic lupus erythematosus (SLE) were treated after discontinuing previous immunosuppressive therapy, according to an intensified protocol, with three plasmaphereses (days 1-3), followed by pulse cyclophosphamide (12 mg/kg i.v. each on days 3-5) and then oral immunosuppression (cyclophosphamide 1-5 mg/kg daily, depending on white blood cell count; prednisone equivalent 2.0 decreasing to 0.1 mg/kg, according to response, for 6 months). The aim of "synchronization" of plasmaphereses with subsequent cyclophosphamide pulse-therapy is to damage pathogenic lymphocyte clones during maximal compensatory activation induced by plasmapheresis. In all patients there was rapid improvement from the nephritis, pneumonitis, cytopenia, CNS abnormalities and polyserositis. The lupus activity index (SLAM) fell clearly, from initially 28.4 (13-37) points to 8.9 (2-13) after 6 months. Treatment was discontinued after this fall in 12 patients. A recurrence was observed in two patients, at 12 and 39 months respectively. Another patient died from liver cirrhosis of unknown aetiology. Nine patients are under observation but without treatment at present, in essential remission after 2 years (5-51 months), with a SLAM of 2.8 (0-7) points. "Synchronization" of plasmaphereses with subsequent pulse cyclophosphamide achieved rapid improvement and it resulted, for the first time, repeatedly in long-term treatment-free clinical remissions.