Seminars in thrombosis and hemostasis
-
Surgical procedures of the liver, such as partial liver resections and liver transplantation, are major types of abdominal surgery. Liver surgery can be associated with excessive intraoperative blood loss, not only because the liver is a highly vascularized organ, but also because it plays a central role in the hemostatic system. Intraoperative blood loss and transfusion of blood products have been shown to be negatively associated with postoperative outcome after liver surgery. ⋯ In patients with liver cirrhosis, there is increasing evidence that factors such as portal hypertension and the hyperdynamic circulation play a more important role in the bleeding tendency than changes in the coagulation system. Therefore, intravenous fluid restriction rather than prophylactic administration of large volumes of blood products (i.e., FFP) is recommended in patients undergoing major liver surgery. Pharmacological agents such as antifibrinolytic drugs or recombinant factor VIIa may be indicated in selected individual patients, but these agents do not have a routine role in the management of patients undergoing liver surgery.
-
Acutely bleeding patients are commonly found in the trauma and major surgery scenarios. They require prompt and effective treatment to restore an adequate hemostatic pattern, to avoid serious and sometimes life-threatening complications. Different prohemostatic treatments are available, including allogeneic blood derivatives (fresh frozen plasma, platelet concentrates, and cryoprecipitates), prothrombin complex concentrates, specific coagulation factors (fibrinogen, recombinant factor XIII, recombinant activated factor VII), and drugs (protamine for patients under heparin treatment, desmopressin, antifibrinolytics). ⋯ This empirical strategy may lead to excessive or unnecessary use of allogeneic blood products, as well as to an incorrect, inefficacious, or even dangerous treatment. Different monitoring devices are nowadays available for guiding the diagnostic and therapeutic decision-making process in an acutely bleeding patient. This review addresses the available tools for monitoring prohemostatic treatment of the bleeding patient, with a specific respect for point-of-care tests (thromboelastography, thromboelastometry, platelet function tests, and heparin monitoring systems) at the light of the existing evidence.
-
Cardiac surgical patients represent a unique group of patients where coagulopathy occurs due to multiple causes besides simple hemorrhagic blood loss. Hemodilution, inflammation, and hemostatic activation while on cardiopulmonary bypass all contribute to this problem and provide targets for therapeutic intervention. Current pharmacological strategies to reduce the need for allogeneic transfusions include both preemptive agents to decrease the potential for bleeding as well as prohemostatic agents to promote the coagulation process. This article will discuss pharmacological agents including antifibrinolytics, protamine, desmopressin, fibrinogen, purified protein concentrates, recombinant factor VIIa, factor XIII, and topical agents used in cardiac surgery.
-
Pharmacological prohemostatic agents may be useful adjunctive treatment options in patients with severe blood loss. The efficacy of these interventions has been established in a variety of clinical situations. ⋯ Several studies have shown that some prohemostatic interventions may indeed increase the risk of arterial and venous thromboembolism, although these complications are relatively rare. When considering the use of adjunctive prohemostatic agents to prevent or treat excessive blood loss, the risk of thrombotic complications should be taken into account.
-
Semin. Thromb. Hemost. · Feb 2012
ReviewActive online assessment of patients using new oral anticoagulants: bleeding risk, compliance, and coagulation analysis.
Clinicians prescribing new oral anticoagulants (OACs; dabigatran, rivaroxaban, and apixaban) should be aware of the exclusion criteria related to bleeding risks defined in published clinical studies. At least a quarter of patients currently using warfarin have an exclusion criterion that may prevent easy transition to the new OACs. In the summary of product characteristics for dabigatran, as an example, the target populations appear generalized. ⋯ Laboratory results are also influenced by clinical situation: e.g. bleed (consumption of coagulation factors) versus postoperative state (activation of coagulation). Without specific antidotes and evidence-based treatment strategies, new OACs are clinically worrisome in patients with impaired renal or liver function. Postmarketing surveillance and recording of bleeding complications (ICD-10 D68.32) are therefore of major importance.