Vascular
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The prospect of surgery without blood loss is an emerging reality. Use of a blood conservation strategy is gaining increasing recognition as a sound and practical approach, especially for the majority of large blood loss surgeries. However, critical situations still occur in which transfusions are necessary or unavoidable for the short-term survival of the patient. ⋯ Increasingly, hospitals are adopting blood conservation strategies as part of their routine practice. Blood conservation is a rapidly evolving field in which active research is expanding our understanding of the molecular, physiologic, and clinical aspects of hematopoiesis, circulatory response, coagulation enigmas, artificial oxygen carriers, and the impact of anemia on organ function. Ongoing research offers the possibility of replacement or elimination of allogeneic blood transfusions in a variety of clinical settings.
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Review Historical Article
Bovine thrombin: history, use, and risk in the surgical patient.
Thrombin is a common hemostatic drug used in surgical practice for over 100 years because of its simplicity and efficacy. Thrombin converts fibrinogen to fibrin, activates platelets, and induces vascular contraction. It is available in multiple forms, including human thrombin, bovine thrombin, and, most recently, human recombinant thrombin. ⋯ Patients with multiple elevated antibodies prior to surgery are also more likely to sustain adverse events. Animal studies confirm these immunological responses seen in humans. With the available clinical and laboratory data, a less immunogenic yet biologically effective thrombin should be available for use in our surgical patients.
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The successful management of patients with arterial or venous vascular disease is increasingly dependent on the effective use of pharmacotherapeutic agents. Anticoagulation therapies for thromboembolic disease are continually improving, and platelet inhibition remains a cornerstone treatment for all patients with atherosclerotic disease. Early ischemic complications can be avoided by proper preoperative prescription, intraoperative management, and postoperative pharmacotherapy. ⋯ Unfractionated or low-molecular-weight heparin, warfarin, and long-term platelet inhibition can improve survival, reduce the risk of other vascular bed ischemic events, and improve the long-term success of the target revascularization procedure. An overview of evidence-based antithrombotic strategies will include a discussion of patients who undergo the two most common open vascular reconstructive procedures, carotid endarterectomy and infrainguinal bypass. The appropriate use of antithrombotic therapy for vascular reconstructive surgery patients has important implications for both short- and long-term patient outcomes.