Vascular
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The objective of this study was to investigate the risk of acute internal jugular, subclavian, and axillary deep venous thrombosis (upper torso DVT [UTDVT]) and pulmonary embolism (PE) and the role of anticoagulation in a cohort of hospitalized patients. A 2-year retrospective review of hospitalized patients who underwent upper torso vein duplex scanning was performed. Patient demographics, underlying comorbidities, indication for scanning, diagnostic tests, intensive care unit stay, length of stay, presence of a central line (current or within the last 2 weeks), malignancy (current or former), hypercoaguable condition, postoperative state, renal failure, mortality, and use of anticoagulation were recorded. ⋯ Patients with a central line (current or within the previous 14 days) were at greatest risk, with an internal jugular vein thrombosis being the most common source. The inconsistent use of anticoagulation therapy for UTDVT was associated with a moderate risk of PE. A survival benefit for anticoagulation could not be documented.
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Intraoperative control of bleeding during any surgical procedure is vital for achieving a positive patient outcome. Hemostasis can be achieved through practical and effective systemic or topical approaches. A variety of hemostatic methods can be employed, ranging from simple manual pressure application with one finger to electrical tissue cauterization, systemic administration of blood products, and systemic administration or topical application of procoagulation agents. ⋯ As with the use of systemically delivered hemostatic agents, topical treatments also carry risks with their use, and their efficacy has not been extensively studied in large randomized, placebo-controlled prospective studies. The effective use of topical agents is highly dependent on the surgeon's experience or preference and their availability in the surgical setting. In this article, we review the currently available topical hemostatic agents, compare their efficacy, and give general recommendations for their use in the operating room.
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Despite improvements in surgical techniques, the risk for perioperative bleeding remains significant. Transfusion of allogeneic red blood cells, platelets, and hemostatic factors remains the mainstay of current therapy strategy for management of perioperative bleeding. ⋯ Pharmacologic strategies to prevent or decrease perioperative bleeding are also important therapeutic approaches to reduce the need for allogeneic transfusions. This article discusses systemic pharmacologic prohemostatic agents (aprotinin, lysine analogues, protamine, desmopressin, and recombinant factor VIIa).
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Heparin is the predominant anticoagulant used in cardiac and vascular surgery. Heparin-induced thrombocytopenia (HIT) is one of the most serious and life-threatening adverse drug reactions associated with heparin use. In addition to the development of thrombocytopenia, HIT is associated with a high risk (40-50%) of thrombotic complications. ⋯ The risk of HIT varies significantly depending on the type of heparin (unfractionated heparin greater than low-molecular-weight heparin), duration of heparin use, and patient population (surgery greater than medical). Readily available serologic assays for serum antibodies against H-PF4 allow for rapid confirmation of a clinical diagnosis of HIT. Owing to the high risk of thrombosis associated with HIT, antithrombotic therapy with direct thrombin inhibitors (lepirudin or argatroban) should be started when serologic assays confirm clinical suspicion.
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To effectively balance bleeding and clotting in surgical patients, the surgeon needs a fundamental knowledge of coagulation biology. The endothelium and activated platelets play crucial roles in coagulation. Activated platelets and damaged endothelial cells provide a platform of negatively charged phospholipids that not only bind coagulation factors and their complexes but also accelerate the conversion of inactive zymogens to active serine proteases. ⋯ Correctly diagnosing and appropriately treating perioperative bleeding in surgical patients require a basic understanding of the most common bleeding and clotting disorders. This article provides an overview of the characteristic features of common coagulopathic conditions and their treatment options. Given the challenge of balancing bleeding and clotting in surgical patients, hemostatic management must be tailored to each patient and should take into account the patient's genetic and acquired risk factors and the acute disturbances in bleeding and clotting caused by surgical intervention.