Seminars in thrombosis and hemostasis
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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.
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Obstetric hemorrhage is a major cause of maternal morbidity and mortality. Pregnancy is associated with substantial hemostatic changes, resulting in a relatively hypercoagulable state. Acquired coagulopathy can, however, develop rapidly in severe obstetric hemorrhage. ⋯ Therefore, until efficacy and safety are demonstrated in obstetric hemorrhage, clinicians should be cautious about wholesale adoption of high FFP:RBC ratio products. Applications of transfusion protocols, dedicated to massive obstetric hemorrhage and multidisciplinarily developed, currently remain the best available option. Similarly, while procoagulant agents appear promising in treatment of obstetric hemorrhage, caution is nonetheless warranted as long as clear evidence in the context of obstetric hemorrhage is lacking.
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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.
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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.
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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.