Pharmacotherapy
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Clinical pharmacists often participate on critical care teams that manage patients with bleeding emergencies. Although blood products are usually dispensed from the blood bank and not the pharmacy, pharmacists should be conversant in the language and trends of transfusion medicine, much like they are with other therapeutic agents. ⋯ Usage patterns, the rationale for administering the various blood products, and studies that have attempted to determine appropriate criteria for ordering transfusions (transfusion triggers) are discussed. The benefits, risks, and several ongoing controversies that relate to the appropriateness and safety of blood product use are also summarized.
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The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are the most commonly prescribed agents for hypercholesterolemia and have revolutionized the management of hyperlipidemia and the area of cardiovascular risk reduction. However, recent data suggest that their effects go well beyond the lipid lowering seen with long-term use and may include acute antiinflammatory activity, anticoagulation, immunomodulation, as well as promotion of changes in smooth-muscle tone. ⋯ More research is necessary to ascertain the true role of statins in the treatment of these various disorders. Nevertheless, the concept of a statin's role as being only a routine preventive therapy with benefits limited to patients undergoing extended treatment is rapidly becoming inaccurate.
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To evaluate the effectiveness and safety of enoxaparin therapy in a neonatal intensive care unit (NICU). ⋯ Enoxaparin may be effective in the treatment of neonatal thrombosis. An initial dosage of 1.5 mg/kg every 12 hours is likely inadequate to obtain therapeutic antifactor Xa levels rapidly and differs for term and preterm neonates. Therapeutic levels in preterm infants may be more variable, and the pharmacokinetics of this drug in preterm infants requires further evaluation. Future studies in neonates should prospectively evaluate a higher starting dose of enoxaparin to document effectiveness, acceptance, compliance with treatment guidelines, and adverse effects.
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Acute hemorrhage is a medical emergency requiring immediate attention, regardless of whether it manifests as blood volume lost and inadequate oxygen delivery, or as a pathologic space-occupying lesion capable of exerting elevated organ-damaging pressures. The most commonly encountered and challenging hemorrhagic emergencies to manage include bleeding secondary to traumatic injury, intracranial hemorrhage, severe gastrointestinal bleeding, and diffuse intraoperative bleeding. ⋯ The agents used to accomplish these goals, however, may differ. Several typical clinical scenarios and the evidence-based approaches used to manage such cases are presented.
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Comparative Study
Key concepts in the management of difficult hemorrhagic cases.
Goals of hemorrhage management involve promoting coagulation and reducing fibrinolysis to enhance clot formation and stability, and minimizing hemorrhagic expansion to reduce the likelihood of adverse outcomes. The optimal hemostatic regimen to obtain these goals will differ according to the clinical scenario. Two hypothetical cases of patients with hemorrhage are presented that are typical of those encountered by clinical pharmacists who practice in centers that treat trauma or surgical patients or patients in need of emergency or critical care because of serious bleeding. To maximize therapy, the clinician must be aware of how best to clinically apply hemostatic agents, their comparative benefits and disadvantages, and the optimal methods for monitoring their effectiveness and toxicities.