Prothrombin Complex Concentrate before Urgent Surgery in Patients Treated with Rivaroxaban and Apixaban.

INTRODUCTION: Patients treated with direct Xa inhibitors may require urgent surgery. Administration of prothrombin complex concentrate (PCC) in this setting is common; however, it is based on limited experience in healthy volunteers. OBJECTIVE: To characterize the population receiving PCC for apixaban/rivaroxaban reversal prior to an urgent surgery and evaluate its efficacy and safety. METHODS: This was a retrospective study in 2 tertiary hospitals. Bleeding was evaluated based on surgical reports, hemoglobin drop, and the use of blood products or additional PCC during 48 h. Safety measures were thrombotic complications and 30-day mortality. RESULTS: Sixty-two patients aged 80.7 ± 9 years, treated with apixaban (39.63%) or rivaroxaban (23.37%), received PCC before an urgent surgery/procedure. Most underwent abdominal operation (61%), orthopedic surgery (13%), or transhepatic cholecystostomy insertion (10%). Bleeding during surgery was reported in 3 patients (5%), no patient required additional PCC, and 16 patients (26%) received packed cells (median: 1 unit, range: 1-5). The 30-day mortality and thrombosis rates were 21% (n = 13) and 3% (n = 2), respectively. The cause of death was related to the primary disease, most commonly sepsis. No patient died due to bleeding/thrombosis. CONCLUSIONS: Our results support the use of PCC to achieve hemostasis in patients treated with Xa inhibitors prior to an urgent surgery.

Percutaneous transluminal angioplasty of an occluded surgical splenorenal shunt in a 4-year-old child after liver transplantation.

Percutaneous transluminal angioplasty is increasingly used in children. We present a case of successful balloon angioplasty of an occluded surgical splenorenal shunt in a 4-year-old child who underwent liver transplantation because of biliary atresia. Percutaneous reopening of the shunt is a relatively safe procedure that may spare patients of surgical intervention.

Ultrasonography in patients without trauma in the emergency department: impact on discharge diagnosis.

OBJECTIVE: The aim of this study was to examine to what extent findings on ultrasonography performed in the emergency department (ED) after hours confirm or alter the referral diagnosis in patients without trauma as reflected in the discharge diagnosis. METHODS: In this prospective study, data from 136 ultrasonographic examinations performed in patients without trauma after hours in the ED during January and February 2002 were evaluated against the suspected preimaging diagnosis of the referring ED physician and the actual discharge diagnosis from the ED or after hospitalization. The rate of preimaging and postimaging concordance was statistically analyzed and compared by calculation of confidence intervals and by the McNemar test. RESULTS: Normal ultrasonographic findings were documented in 54 patients (40%), and pathologic findings were documented in 82 (60%). Thirty-four (25%) of the 136 examinations were concordant with the initial referring physician's diagnosis. Of the 102 studies that were not concordant with the initial referral suspected diagnoses, that is, being either a study with normal findings or offering an alternative diagnosis, 81 (79.4%) were concordant with the discharge diagnosis. CONCLUSIONS: After-hours ultrasonographic findings in patients without trauma seen in the ED seem to have a high impact on the discharge diagnosis and are concordant with it in more than 80% of cases.