101
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Götz M, Biecker E, Dechêne A, Schilling D, Zipprich A, Trebicka J. [Not Available]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:1139-1145. [PMID: 35817045 DOI: 10.1055/a-1788-3501] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Martin Götz
- Medizinische Klinik IV - Gastroenterologie/Onkologie, Klinikum Sindelfingen-Böblingen, Böblingen, Deutschland
| | - Erwin Biecker
- Abteilung Innere Medizin mit Schwerpunkt Gastroenterologie, Zollernalb Klinikum Balingen, Balingen, Deutschland
| | - Alexander Dechêne
- Medizinische Klinik 6 mit Schwerpunkt Gastroenterologie, Klinikum Nord, Nürnberg, Deutschland
| | - Dieter Schilling
- Medizinische Klinik II mit Schwerpunkt Gastroenterologie, Diakonissenkrankenhaus Mannheim, Mannheim, Deutschland
| | - Alexander Zipprich
- Klinik für Innere Medizin IV Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
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102
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Spinella PC, Bochicchio K, Thomas KA, Staudt A, Shea SM, Pusateri AE, Schuerer D, Levy JH, Cap AP, Bochicchio G. The risk of thromboembolic events with early intravenous 2- and 4-g bolus dosing of tranexamic acid compared to placebo in patients with severe traumatic bleeding: A secondary analysis of a randomized, double-blind, placebo-controlled, single-center trial. Transfusion 2022; 62 Suppl 1:S139-S150. [PMID: 35765921 DOI: 10.1111/trf.16962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Screening for the risk of thromboembolism (TE) due to tranexamic acid (TXA) in patients with severe traumatic injury has not been performed in randomized clinical trials. Our objective was to determine if TXA dose was independently-associated with thromboembolism. STUDY DESIGN AND METHODS This is a secondary analysis of a single-center, double-blinded, randomized controlled trial comparing placebo to a 2-g or 4-g intravenous TXA bolus dose in trauma patients with severe injury. We used multivariable discrete-time Cox regression models to identify associations with risk for thromboembolic events within 30 days post-enrollment. Event curves were created using discrete-time Cox regression. RESULTS There were 50 patients in the placebo group, 49 in the 2-g, and 50 in the 4-g TXA group. In adjusted analyses for thromboembolism, a 2-g dose of TXA had an hazard ratio (HR, 95% confidence interval [CI]) of 3.20 (1.12-9.11) (p = .029), and a 4-g dose of TXA had an HR (95% CI) of 5.33 (1.94-14.63) (p = .001). Event curves demonstrated a higher probability of thromboembolism for both doses of TXA compared to placebo. Other parameters independently associated with thromboembolism include time from injury to TXA administration, body mass index, and total blood products transfused. DISCUSSION In patients with severe traumatic injury, there was a dose-dependent increase in the risk of at least one thromboembolic event with TXA. TXA should not be withheld, but thromboembolism screening should be considered for patients receiving a dose of at least 2-g TXA intravenously for traumatic hemorrhage.
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Affiliation(s)
- Philip C Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kelly Bochicchio
- Department of Surgery, Division of Acute Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kimberly A Thomas
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amanda Staudt
- Clinical Research Support Branch, The Geneva Foundation, Fort Sam Houston, Texas, USA
| | - Susan M Shea
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Douglas Schuerer
- Department of Surgery, Division of Acute Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina USA, Durham, North Carolina-NC, 27710, USA
| | - Andrew P Cap
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Grant Bochicchio
- Department of Surgery, Division of Acute Care Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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103
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Tran QK, Tang K, Pourmand A. Tranexamic acid and Gastrointestinal bleed: Effect of the HALT-IT trial on current meta-analysis. Am J Emerg Med 2022; 59:165-167. [PMID: 35778062 DOI: 10.1016/j.ajem.2022.06.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 12/19/2022] Open
Affiliation(s)
- Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States of America; The Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
| | - Kaitlyn Tang
- The Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America.
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104
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Erasu V, Novak A, Gibbs VN, Champaneria R, Dorée C, Hafeez A, Moy R, Sandercock J, Brunskill SJ, Estcourt LJ. Pharmacological interventions for the treatment of bleeding in people treated for blunt force or penetrating injury in an emergency department: a systematic review and network meta-analysis. Hippokratia 2022. [DOI: 10.1002/14651858.cd014600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Vishakha Erasu
- Emergency Medicine Research Oxford (EMROx); Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Alex Novak
- Emergency Medicine Research Oxford (EMROx); Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Victoria N Gibbs
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Rita Champaneria
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Carolyn Dorée
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Aqib Hafeez
- Emergency Medicine Research Oxford (EMROx); Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Ross Moy
- Emergency Medicine Research Oxford (EMROx); Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Josie Sandercock
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | | | - Lise J Estcourt
- Haematology/Transfusion Medicine; NHS Blood and Transplant; Oxford UK
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105
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Callum J, Tresierra S, Woolley T. Major haemorrhage: putting evidence into practice. Br J Haematol 2022; 198:619-622. [PMID: 35687759 DOI: 10.1111/bjh.18246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/01/2022] [Accepted: 05/01/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University and Kingston Health Sciences Centre, Kingston, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Steven Tresierra
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Thomas Woolley
- Anaesthetics and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
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106
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Stanworth SJ, Dowling K, Curry N, Doughty H, Hunt BJ, Fraser L, Narayan S, Smith J, Sullivan I, Green L. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol 2022; 198:654-667. [PMID: 35687716 DOI: 10.1111/bjh.18275] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Kerry Dowling
- Transfusion Laboratory Manager, Southampton University Hospitals NHS Foundation Trust, Southampton, UK
| | - Nikki Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Heidi Doughty
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Beverley J Hunt
- Department of Haematology, Guy's and St Thomas's Hospital, London, UK
| | - Laura Fraser
- Transfusion Practitioner, NHS Lanarkshire, University Hospital Wishaw, Wishaw, UK.,National Services Scotland/Scottish National Blood Transfusion, Edinburgh, UK
| | - Shruthi Narayan
- Medical director, Serious Hazards of Transfusion, Manchester, UK
| | - Juliet Smith
- Lead Transfusion Practitioner, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Sullivan
- Transfusion Laboratory Manager, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Laura Green
- Transfusion Medicine, NHS Blood and Transplant, London, UK.,Barts Health NHS Trust, London, UK.,Blizzard Institute, Queen Mary University of London, London, UK
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107
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Lisman T, Caldwell SH, Intagliata NM. Haemostatic alterations and management of haemostasis in patients with cirrhosis. J Hepatol 2022; 76:1291-1305. [PMID: 35589251 DOI: 10.1016/j.jhep.2021.11.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022]
Abstract
Patients with cirrhosis frequently acquire complex changes in their haemostatic system including a decreased platelet count and decreased levels of various haemostatic proteins. Although historically patients with cirrhosis were thought to have a haemostasis-related bleeding tendency, it is now widely accepted that the haemostatic system of patients with cirrhosis remains in balance as a result of simultaneous changes in pro- and anti-haemostatic systems. The concept of rebalanced haemostasis has led to changes in clinical management, although firm evidence from well-designed clinical studies is largely lacking. For example, many invasive procedures in patients with cirrhosis and a prolonged prothrombin time are now performed without prophylaxis with fresh frozen plasma. Conversely, clinicians have become more aware of the need for anti-thrombotic therapy, even in those patients with abnormal routine coagulation tests. This paper will outline recent advances in pathogenesis, prevention and treatment of both bleeding and thrombotic complications in patients with cirrhosis. Among other topics, we will discuss the haemostatic status of acutely ill patients with cirrhosis, the various causes of bleeding in patients with cirrhosis, and how best to prevent or treat bleeding. In addition, we will discuss the hypercoagulable features of patients with cirrhosis, new insights into the pathogenesis of portal vein thrombosis, and how best to prevent or treat thromboses.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Coagulation in Liver Disease, University of Virginia Medical Center, Charlottesville VA, United States
| | - Nicolas M Intagliata
- Division of Gastroenterology and Hepatology, Department of Medicine, Center for Coagulation in Liver Disease, University of Virginia Medical Center, Charlottesville VA, United States
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108
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Tranexamic acid – A narrative review for the emergency medicine clinician. Am J Emerg Med 2022; 56:33-44. [DOI: 10.1016/j.ajem.2022.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 02/06/2023] Open
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109
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EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
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110
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Fowler H, Law J, Tham SM, Gunaravi SA, Houghton N, Clifford RE, Fok M, Barker JA, Vimalachandran D. Impact on blood loss and transfusion rates following administration of tranexamic acid in major oncological abdominal and pelvic surgery: A systematic review and meta-analysis. J Surg Oncol 2022; 126:609-621. [PMID: 35471705 DOI: 10.1002/jso.26900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/03/2022] [Accepted: 04/04/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Major bleeding and receiving blood products in cancer surgery are associated with increased postoperative complications and worse outcomes. Tranexamic acid (TXA) reduces blood loss and improves outcomes in various surgical specialities. We performed a systematic review and meta-analysis to investigate TXA use on blood loss in elective abdominal and pelvic cancer surgery. METHODS A literature search was performed for studies comparing intravenous TXA versus placebo/no TXA in patients undergoing major elective abdominal or pelvic cancer surgery. RESULTS Twelve articles met the inclusion criteria, consisting of 723 patients who received TXA and 659 controls. Patients receiving TXA were less likely to receive a red blood cell (RBC) transfusion (p < 0.001, OR 0.4 95% CI [0.25, 0.63]) and experienced less blood loss (p < 0.001, MD -197.8 ml, 95% CI [-275.69, -119.84]). The TXA group experienced a smaller reduction in haemoglobin (p = 0.001, MD -0.45 mmol/L, 95% CI [-0.73, -0.18]). There was no difference in venous thromboembolism (VTE) rates (p = 0.95, OR 0.98, 95% CI [0.46, 2.08]). CONCLUSIONS TXA use reduced blood loss and RBC transfusion requirements perioperatively, with no significant increased risk of VTE. However, further studies are required to assess its benefit for cancer surgery in some sub-specialities.
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Affiliation(s)
- Hayley Fowler
- Department of Colorectal Surgery, Countess of Chester NHS Foundation Trust, Chester, UK.,Institute of Systems Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | | | - Su Ming Tham
- Department of Colorectal Surgery, Countess of Chester NHS Foundation Trust, Chester, UK
| | - Sisyena A Gunaravi
- Department of Colorectal Surgery, Countess of Chester NHS Foundation Trust, Chester, UK
| | | | - Rachael E Clifford
- Institute of Systems Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Matthew Fok
- Department of Colorectal Surgery, Countess of Chester NHS Foundation Trust, Chester, UK.,Institute of Systems Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Jonathan A Barker
- Health Education England, Manchester, UK.,Department of Colorectal Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Dale Vimalachandran
- Department of Colorectal Surgery, Countess of Chester NHS Foundation Trust, Chester, UK.,Institute of Systems Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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111
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Shettar SS, Vandyck K, Tanaka KA. Coagulation Management in End-Stage Liver Disease. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00524-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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112
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Brown NJ, Wilson B, Ong V, Gendreau JL, Yang CY, Himstead AS, Shahrestani S, Shlobin NA, Reardon T, Choi EH, Birkenbeuel J, Cohn SJ, Sahyouni R, Yang I. Use of Tranexamic Acid for Elective Resection of Intracranial Neoplasms: A Systematic Review. World Neurosurg 2022; 160:e209-e219. [PMID: 34995825 DOI: 10.1016/j.wneu.2021.12.117] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND As an established antifibrinolytic agent, tranexamic acid (TXA) has garnered widespread use during surgery to limit intraoperative blood loss. In the field of neurosurgery, TXA is often introduced in cases of traumatic brain injury or elective spine surgeries; however, its role during elective cranial surgeries is not well established. We report a systematic review of the use of TXA in elective surgical resection of intracranial neoplasms. METHODS We performed this systematic review following PRISMA guidelines to identify studies investigating the use of TXA in elective neurosurgical resection of intracranial neoplasms. Variables extracted included patient demographics, surgical indications, type of surgery performed, TXA dose and route of administration, operative duration, blood loss, transfusion rate, postoperative hemoglobin level, and complications. RESULTS After careful screening, 4 articles (consisting of 682 patients) met our inclusion/exclusion criteria. The studies included 2 prospective cohort studies, 1 retrospective cohort study, and 1 case series. A χ2 test of pooled data demonstrated that patients administered TXA had a significantly decreased need for blood transfusions during surgery (odds ratio, 0.6273; 95% confidence interval, 0.4254-0.9251; P = 0.018). Mean total blood loss was 821.9 mL in the TXA group and 1099.0 mL in the control group across the studies. There was no significant difference in postoperative hemoglobin levels, with a mean of 11.4 g/dL in both the TXA and control groups. CONCLUSIONS These results support the use of intraoperative TXA in tumor resection. However, its role in tumor resection has been less well investigated compared with its use in other areas of neurosurgery.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Bayard Wilson
- Department of Neurological Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Vera Ong
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Julian L Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA.
| | - Chen Yi Yang
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Alexander S Himstead
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Shane Shahrestani
- Keck School of Medicine of USC, Los Angeles, California, USA; Medical Scientist Training Program, California Institute of Technology, Pasadena, California, USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, Kentucky, USA
| | - Elliot H Choi
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Jack Birkenbeuel
- Department of Neurological Surgery, University of California Irvine, Irvine, California, USA
| | - Sebastian J Cohn
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ronald Sahyouni
- Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
| | - Isaac Yang
- Department of Neurological Surgery, University of California Los Angeles, Los Angeles, California, USA
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113
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Ting KH, Shiu BH, Yang SF, Liao PL, Huang JY, Chen YY, Yeh CB. Risk of Mortality among Patients with Gastrointestinal Bleeding with Early and Late Treatment with Tranexamic Acid: A Population-Based Cohort Study. J Clin Med 2022; 11:jcm11061741. [PMID: 35330064 PMCID: PMC8951209 DOI: 10.3390/jcm11061741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 02/06/2023] Open
Abstract
Tranexamic acid (TXA) is an antifibrinolytic pharmacological agent, but its use in gastrointestinal bleeding remains contentious. Moreover, studies on the timing of TXA administration are limited. We examined whether early TXA administration reduced the risk of mortality in patients with gastrointestinal bleeding in a Taiwanese population. We used the National Health Insurance Research Database to identify patients diagnosed with gastrointestinal bleeding with early and late TXA treatment. We defined early treatment as initial TXA treatment in an emergency department and late treatment as initial TXA treatment after hospitalization. Mortality within 52 weeks was the primary outcome. A multivariable analysis using a multiple Cox regression model was applied for data analysis. Propensity score matching (PSM) was performed to reduce the potential for bias caused by measured confounding variables. Of the 52,949 selected patients with gastrointestinal bleeding, 5127 were assigned to either an early or late TXA treatment group after PSM. The incidence of mortality was significantly decreased during the first and fourth weeks (adjusted HR (aHR): 0.65, 95% CI: 0.56−0.75). A Kaplan−Meier curve revealed a significant decrease in cumulative incidence of mortality in the early TXA treatment group (log-rank test: p < 0.0001). Multiple Cox regression analysis revealed significantly lower mortality in the early TXA treatment group compared with the late treatment group (aHR: 0.64, 95% CI: 0.57−0.73). Thromboembolic events were not significantly associated with early or late TXA treatment (aHR: 1.03, 95% CI: 0.94−1.12). A Kaplan−Meier curve also revealed no significant difference in either venous or arterial events (log-rank test: p = 0.3654 and 0.0975, respectively). In conclusion, early TXA treatment was associated with a reduced risk of mortality in patients with gastrointestinal bleeding compared with late treatment, without an increase in thromboembolic events. The risk of rebleeding and need for urgent endoscopic intervention require further randomized clinical trials.
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Affiliation(s)
- Ke-Hsin Ting
- Division of Cardiology, Department of Internal Medicine, Changhua Christian Hospital, Yunlin Branch, Yunlin 648, Taiwan;
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
| | - Bei-Hao Shiu
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
| | - Shun-Fa Yang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Pei-Lun Liao
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Jing-Yang Huang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402, Taiwan
| | - Yin-Yang Chen
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Surgery, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Correspondence: (Y.-Y.C.); (C.-B.Y.)
| | - Chao-Bin Yeh
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan; (B.-H.S.); (S.-F.Y.); (P.-L.L.); (J.-Y.H.)
- Department of Emergency Medicine, School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Correspondence: (Y.-Y.C.); (C.-B.Y.)
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114
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Ausen K, Fossmark R, Spigset O, Pleym H. Safety and Efficacy of Local Tranexamic Acid for the Prevention of Surgical Bleeding in Soft-Tissue Surgery: A Review of the Literature and Recommendations for Plastic Surgery. Plast Reconstr Surg 2022; 149:774-787. [PMID: 35196701 PMCID: PMC8860217 DOI: 10.1097/prs.0000000000008884] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 04/13/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although high-bleed surgery routinely utilizes the antifibrinolytic drug tranexamic acid, most plastic surgical procedures are conducted in soft tissue with low-volume bleeding. Unease regarding possible systemic adverse effects prevents widespread systemic use, but local use of tranexamic acid is gaining popularity among plastic surgeons. Randomized controlled trials on topical use of tranexamic acid are mainly from high-bleed surgeries, and few studies address the effect in soft tissue. This article reviews the scientific evidence regarding local use of tranexamic acid in soft-tissue surgery, discusses pharmacological effects and possible adverse reactions, and presents recommendations for use in plastic surgery. METHODS A systematic search of databases for studies on local use of tranexamic acid in soft-tissue surgery was performed. Randomized controlled trials were included for a systematic review on effect; a narrative review regarding other clinically relevant aspects is based on extensive literature searches combined with the authors' own research. RESULTS Fourteen randomized controlled trials, including 1923 patients, were included in the systematic review on local use of tranexamic acid in soft-tissue surgery. CONCLUSIONS Local use of tranexamic acid may reduce blood loss comparably to intravenous prophylactic use with negligible risk of systemic adverse effects, but high-quality randomized controlled trials are few. Prolonged exposure to high local concentrations is discouraged, and direct contact with the central nervous system may cause seizures. No single superior means of administration or dosage is supported in the literature, and lowest effective dose is unknown. There may not be one single ideal dosing regimen, but rather many possibilities adaptable for different surgical situations.
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Affiliation(s)
- Kjersti Ausen
- From the Section for Plastic and Reconstructive Surgery, Clinic of Surgery, Department of Clinical Pharmacology, and Clinic of Anesthesia and Intensive Care, St. Olav’s University Hospital; and Departments of Circulation and Medical Imaging and Clinical and Molecular Medicine, Norwegian University of Science and Technology
| | - Reidar Fossmark
- From the Section for Plastic and Reconstructive Surgery, Clinic of Surgery, Department of Clinical Pharmacology, and Clinic of Anesthesia and Intensive Care, St. Olav’s University Hospital; and Departments of Circulation and Medical Imaging and Clinical and Molecular Medicine, Norwegian University of Science and Technology
| | - Olav Spigset
- From the Section for Plastic and Reconstructive Surgery, Clinic of Surgery, Department of Clinical Pharmacology, and Clinic of Anesthesia and Intensive Care, St. Olav’s University Hospital; and Departments of Circulation and Medical Imaging and Clinical and Molecular Medicine, Norwegian University of Science and Technology
| | - Hilde Pleym
- From the Section for Plastic and Reconstructive Surgery, Clinic of Surgery, Department of Clinical Pharmacology, and Clinic of Anesthesia and Intensive Care, St. Olav’s University Hospital; and Departments of Circulation and Medical Imaging and Clinical and Molecular Medicine, Norwegian University of Science and Technology
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115
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Lai Y, Masatoshi H, Ma Y, Guo Y, Zhang B. Role of Vitamin K in Intestinal Health. Front Immunol 2022; 12:791565. [PMID: 35069573 PMCID: PMC8769504 DOI: 10.3389/fimmu.2021.791565] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
Intestinal diseases, such as inflammatory bowel diseases (IBDs) and colorectal cancer (CRC) generally characterized by clinical symptoms, including malabsorption, intestinal dysfunction, injury, and microbiome imbalance, as well as certain secondary intestinal disease complications, continue to be serious public health problems worldwide. The role of vitamin K (VK) on intestinal health has drawn growing interest in recent years. In addition to its role in blood coagulation and bone health, several investigations continue to explore the role of VK as an emerging novel biological compound with the potential function of improving intestinal health. This study aims to present a thorough review on the bacterial sources, intestinal absorption, uptake of VK, and VK deficiency in patients with intestinal diseases, with emphasis on the effect of VK supplementation on immunity, anti-inflammation, intestinal microbes and its metabolites, antioxidation, and coagulation, and promoting epithelial development. Besides, VK-dependent proteins (VKDPs) are another crucial mechanism for VK to exert a gastroprotection role for their functions of anti-inflammation, immunomodulation, and anti-tumorigenesis. In summary, published studies preliminarily show that VK presents a beneficial effect on intestinal health and may be used as a therapeutic drug to prevent/treat intestinal diseases, but the specific mechanism of VK in intestinal health has yet to be elucidated.
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Affiliation(s)
- Yujiao Lai
- State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Hori Masatoshi
- Department of Veterinary Pharmacology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - Yanbo Ma
- Department of Animal Physiology, College of Animal Science and Technology, Henan University of Science and Technology, Luoyang, China
| | - Yuming Guo
- State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
| | - Bingkun Zhang
- State Key Laboratory of Animal Nutrition, College of Animal Science and Technology, China Agricultural University, Beijing, China
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116
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Honeybul S, Ho KM, Rosenfeld JV. The role of tranexamic acid in traumatic brain injury. J Clin Neurosci 2022; 99:1-4. [PMID: 35220154 DOI: 10.1016/j.jocn.2022.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/12/2022] [Accepted: 02/17/2022] [Indexed: 12/29/2022]
Abstract
Evidence from recent trials evaluating efficacy of antifibrinolytic agents in the context of traumatic brain injury may lead to changes in the management of patients with traumatic brain injury. Tranexamic acid (TXA) reduces the proteolytic action of plasmin on fibrin clots, resulting in an inhibition of fibrinolysis and stabilisation of established blood clots. There has been significant interest in use of the drug as a therapeutic agent in the context of severe haemorrhage; however, considerable controversies regarding its efficacy remain. A number of trials have demonstrated a small but significant decrease in mortality following its administration, but the results have been somewhat inconsistent and may not be generalisable. The results of the CRASH-3 trial were that there was no statistical difference in the number of traumatic brain injury related deaths (18.5% with TXA and 19.8% with placebo; relative risk [RR] 0·94; 95% confidence interval [CI] 0·86-1·02). Nonetheless, there was a subgroup of patients for whom TXA appeared to provide benefit, and this was in patients with mild and moderate injury (with a Glasgow Coma Score > 8). This is potentially a very important finding that may have huge potential implications; however, we believe it does not currently provide indisputable evidence to support the administration of TXA to all patients with TBI. Further work is required to better define the subset of patients who may benefit as well as to evaluate the long-term functional benefit in order to determine which types of severe traumatic brain injury patients would derive more benefits than harms from TXA.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia 6009, Australia; Royal Perth Hospital, Wellington Street, Perth, Australia.
| | - Kwok M Ho
- Department of Intensive Care Medicine and School of Population Health, University of Western Australia, Australia
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, The Alfred Hospital, Emeritus Professor of Surgery Monash University, Melbourne, Australia; Surgery, F.Edward Hebert School of Medicine, Uniformed, Services University of the Health Sciences, Bethesda, MD, USA
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117
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Choi YS, Kim TW, Chang MJ, Kang SB, Chang CB. Enhanced recovery after surgery for major orthopedic surgery: a narrative review. Knee Surg Relat Res 2022; 34:8. [PMID: 35193701 PMCID: PMC8864772 DOI: 10.1186/s43019-022-00137-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 02/08/2022] [Indexed: 12/17/2022] Open
Abstract
Background With increasing interest in enhanced recovery after surgery (ERAS), the literature on ERAS in orthopedic surgery is also rapidly accumulating. This review article aims to (1) summarize the components of the ERAS protocol applied to orthopedic surgery, (2) evaluate the outcomes of ERAS in orthopedic surgery, and (3) suggest practical strategies to implement the ERAS protocol successfully. Main body Overall, 17 components constituting the highly recommended ERAS protocol in orthopedic surgery were identified. In the preadmission period, preadmission counseling and the optimization of medical conditions were identified. In the preoperative period, avoidance of prolonged fasting, multimodal analgesia, and prevention of postoperative nausea and vomiting were identified. During the intraoperative period, anesthetic protocols, prevention of hypothermia, and fluid management, urinary catheterization, antimicrobial prophylaxis, blood conservation, local infiltration analgesia and local nerve block, and surgical factors were identified. In the postoperative period, early oral nutrition, thromboembolism prophylaxis, early mobilization, and discharge planning were identified. ERAS in orthopedic surgery reduced postoperative complications, hospital stay, and cost, and improved the patient outcomes and satisfaction with accelerated recovery. For successful implementation of the ERAS protocol, various strategies including the standardization of care system, multidisciplinary communication and collaboration, ERAS education, and continuous audit system are necessary. Conclusion The ERAS pathway enhanced patient recovery with a shortened length of stay, reduced postoperative complications, and improved patient outcomes and satisfaction. However, despite the significant progress in ERAS implementation in recent years, it has mainly focused on major surgeries such as arthroplasty. Therefore, further efforts to apply, audit, and optimize ERAS in various orthopedic surgeries are necessary.
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Affiliation(s)
- Yun Seong Choi
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul, South Korea
| | - Tae Woo Kim
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul, South Korea
| | - Moon Jong Chang
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul, South Korea
| | - Seung-Baik Kang
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul, South Korea.,Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
| | - Chong Bum Chang
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea. .,Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea.
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118
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Blasi A, Patel VC, Spanke ENHE, Adelmeijer J, Stamouli M, Zamalloa A, Corcoran E, Calvo A, Fernandez J, Bernal W, Lisman T. Fibrin clot quality in acutely ill cirrhosis patients: Relation with outcome and improvement with coagulation factor concentrates. Liver Int 2022; 42:435-443. [PMID: 34894081 PMCID: PMC9299765 DOI: 10.1111/liv.15132] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/13/2021] [Accepted: 12/02/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND & AIMS Patients with liver disease may acquire substantial changes in their hemostatic system, which are most pronounced in patients who are critically ill. Changes in the quality of the fibrin clot in critically ill patients have not been studied in detail. Here we assessed markers of fibrin clot quality and effects of coagulation factor concentrates in patients with acutely decompensated (AD) cirrhosis and acute on chronic liver failure (ACLF). METHODS We measured plasma levels of fibrinogen, factor XIII, prothrombin and performed thrombin generation assays in 52 AD patients, 58 ACLF patients and 40 controls. In addition, we examined the effects of coagulation factor concentrates on functional assays of fibrin quality. RESULTS We found increased thrombin generating capacity in both AD and ACLF in comparison with healthy controls. Plasma levels of prothrombin, fibrinogen, and factor XIII were lower in patients compared to controls, appeared lower in ACLF compared to AD patients, and were related to clinical outcomes. Fibrinogen concentrate, but not factor XIII or prothrombin complex concentrate, improved clot quality in vitro. Prothrombin complex concentrate increased the resistance of the clot to break down. CONCLUSIONS We have demonstrated elevated thrombin generation but decreased plasma levels of prothrombin, fibrinogen and FXIII in acutely ill patients with cirrhosis. In addition, we showed that fibrinogen concentrate and PCCs, but not factor XIII concentrate, improve clot properties in patient plasma. Whether there is true clinical benefit from coagulation factor concentrates in prevention or treatment of bleeding requires further study. LAY SUMMARY Patients with liver diseases are at risk of bleeding, but mechanisms involved in this bleeding risk are incompletely understood. We studied components that determine the stability of the blood clot and found that concentrations of certain proteins involved in clot stability are present in low levels in acutely ill patients with liver disease. We furthermore demonstrated that some clinically available drugs improve the stability of blood clots from these patients in a test tube.
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Affiliation(s)
- Annabel Blasi
- Anesthesiology DepartmentHospital Clínic and University of BarcelonaBarcelonaSpain,Institute d'Investigacions Biomèdica Agustí Pi i Sunyer (IDIBAPS)BarcelonaSpain
| | - Vishal C. Patel
- Institute of Liver Studies & TransplantationKing's College HospitalNHS Foundation TrustLondonUK,Liver SciencesSchool of Immunology & Microbial SciencesKing's College LondonUK,Institute of HepatologyFoundation for Liver ResearchLondonUK
| | - Eva N. H. E. Spanke
- Surgical Research LaboratoryDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Jelle Adelmeijer
- Surgical Research LaboratoryDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | | | - Ane Zamalloa
- Institute of Liver Studies & TransplantationKing's College HospitalNHS Foundation TrustLondonUK
| | - Eleanor Corcoran
- Department of Critical CareKing's College Hospital NHS Foundation TrustLondonUK
| | - Andrea Calvo
- Anesthesiology DepartmentHospital Clínic and University of BarcelonaBarcelonaSpain,Institute d'Investigacions Biomèdica Agustí Pi i Sunyer (IDIBAPS)BarcelonaSpain
| | - Javier Fernandez
- Liver UnitInstitut de Malalties Digestives i MetabòliquesHospital Clínic and University of BarcelonaBarcelonaSpain
| | - William Bernal
- Institute of Liver Studies & TransplantationKing's College HospitalNHS Foundation TrustLondonUK
| | - Ton Lisman
- Surgical Research LaboratoryDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands,Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
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119
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Luther J, Friedman LS. Management of Thrombocytopenia and Coagulopathy in Patients with Chronic Liver Disease Undergoing Therapeutic Endoscopic Interventions. Clin Liver Dis 2022; 26:1-12. [PMID: 34802655 DOI: 10.1016/j.cld.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Management of coagulopathy in patients with advanced liver disease undergoing therapeutic endoscopic procedures is complex. Improvements in the understanding of hemostasis at a physiologic level have highlighted the inaccuracy of currently available clinical tests, like platelet count and prothrombin time, in estimating hemostasis in patients with cirrhosis. With identification of novel factors that contribute to bleeding risk in patients with cirrhosis, there is a dearth of clinical trial data that account for all potentially relevant factors and that examine interventions to reduce bleeding risk. Precise recommendations regarding transfusion strategies based on hemostatic test results in patients with cirrhosis are impractical.
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Affiliation(s)
- Jay Luther
- MGH Alcohol Liver Center, Boston, MA, USA; Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Blake 4, 55 Fruit Street, Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lawrence S Friedman
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Blake 4, 55 Fruit Street, Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Department of Medicine, Newton-Wellesley Hospital, Newton, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
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120
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Marcucci M, Painter TW, Conen D, Leslie K, Lomivorotov VV, Sessler D, Chan MTV, Borges FK, Martínez Zapata MJ, Wang CY, Xavier D, Ofori SN, Landoni G, Efremov S, Kleinlugtenbelt YV, Szczeklik W, Schmartz D, Garg AX, Short TG, Wittmann M, Meyhoff CS, Amir M, Torres D, Patel A, Duceppe E, Ruetzler K, Parlow JL, Tandon V, Wang MK, Fleischmann E, Polanczyk CA, Jayaram R, Astrakov SV, Rao M, VanHelder T, Wu WKK, Cheong CC, Ayad S, Abubakirov M, Kirov M, Bhatt K, de Nadal M, Likhvantsev V, Iglesisas PP, Aguado HJ, McGillion M, Lamy A, Whitlock RP, Roshanov P, Stillo D, Copland I, Vincent J, Balasubramanian K, Bangdiwala SI, Biccard B, Kurz A, Srinathan S, Petit S, Eikelboom J, Richards T, Gross PL, Alfonsi P, Guyatt G, Belley-Cote E, Spence J, McIntyre W, Yusuf S, Devereaux PJ. Rationale and design of the PeriOperative ISchemic Evaluation-3 (POISE-3): a randomized controlled trial evaluating tranexamic acid and a strategy to minimize hypotension in noncardiac surgery. Trials 2022; 23:101. [PMID: 35101083 PMCID: PMC8805242 DOI: 10.1186/s13063-021-05992-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/29/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
For patients undergoing noncardiac surgery, bleeding and hypotension are frequent and associated with increased mortality and cardiovascular complications. Tranexamic acid (TXA) is an antifibrinolytic agent with the potential to reduce surgical bleeding; however, there is uncertainty about its efficacy and safety in noncardiac surgery. Although usual perioperative care is commonly consistent with a hypertension-avoidance strategy (i.e., most patients continue their antihypertensive medications throughout the perioperative period and intraoperative mean arterial pressures of 60 mmHg are commonly accepted), a hypotension-avoidance strategy may improve perioperative outcomes.
Methods
The PeriOperative Ischemic Evaluation (POISE)-3 Trial is a large international randomized controlled trial designed to determine if TXA is superior to placebo for the composite outcome of life-threatening, major, and critical organ bleeding, and non-inferior to placebo for the occurrence of major arterial and venous thrombotic events, at 30 days after randomization. Using a partial factorial design, POISE-3 will additionally determine the effect of a hypotension-avoidance strategy versus a hypertension-avoidance strategy on the risk of major cardiovascular events, at 30 days after randomization. The target sample size is 10,000 participants. Patients ≥45 years of age undergoing noncardiac surgery, with or at risk of cardiovascular and bleeding complications, are randomized to receive a TXA 1 g intravenous bolus or matching placebo at the start and at the end of surgery. Patients, health care providers, data collectors, outcome adjudicators, and investigators are blinded to the treatment allocation. Patients on ≥ 1 chronic antihypertensive medication are also randomized to either of the two blood pressure management strategies, which differ in the management of patient antihypertensive medications on the morning of surgery and on the first 2 days after surgery, and in the target mean arterial pressure during surgery. Outcome adjudicators are blinded to the blood pressure treatment allocation. Patients are followed up at 30 days and 1 year after randomization.
Discussion
Bleeding and hypotension in noncardiac surgery are common and have a substantial impact on patient prognosis. The POISE-3 trial will evaluate two interventions to determine their impact on bleeding, cardiovascular complications, and mortality.
Trial registration
ClinicalTrials.gov NCT03505723. Registered on 23 April 2018.
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121
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Green L, Stanworth S, McQuilten Z, Lin V, Tucker H, Jackson B, Badawi M, Hindawi S, Chaurasia R, Patidar G, Pandey HC, Fasola F, Miyata S, Matsumoto M, Matsushita T, Rahimi-Levene N, Peer V, Pavenski K, Callum J, Thompson T, Murphy M, Staves J, Maegele M, Abeyakoon C, Rushford K, Wood E, Nuñez MA, Mellado S, Saa E, Triyono T, Pratomo B, Apelseth TO, Dunbar N. International Forum on the Management of Major Haemorrhage: Summary. Vox Sang 2022; 117:746-753. [PMID: 35050497 DOI: 10.1111/vox.13244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 12/24/2022]
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122
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Green L, Stanworth S, McQuilten Z, Lin V, Tucker H, Jackson B, Badawi M, Hindawi S, Chaurasia R, Patidar G, Pandey HC, Fasola F, Miyata S, Matsumoto M, Matsushita T, Rahimi-Levene N, Peer V, Pavenski K, Callum J, Thompson T, Murphy M, Staves J, Maegele M, Abeyakoon C, Rushford K, Wood E, Nuñez MA, Mellado S, Saa E, Triyono T, Pratomo B, Apelseth TO, Dunbar N. International Forum on the Management of Major Haemorrhage: Responses. Vox Sang 2022; 117:E58-E74. [PMID: 35050501 DOI: 10.1111/vox.13243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
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123
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Roberts LN, Lisman T, Stanworth S, Hernandez-Gea V, Magnusson M, Tripodi A, Thachil J. Periprocedural management of abnormal coagulation parameters and thrombocytopenia in patients with cirrhosis: Guidance from the SSC of the ISTH. J Thromb Haemost 2022; 20:39-47. [PMID: 34661370 DOI: 10.1111/jth.15562] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/05/2021] [Accepted: 10/11/2021] [Indexed: 12/12/2022]
Abstract
Prolonged prothrombin time and thrombocytopenia are common in patients with cirrhosis. These parameters do not reflect the overall hemostatic rebalance or bleeding risk in the periprocedural setting; however, attempts to correct these parameters remain frequent. We review the literature on periprocedural bleeding risk, bleeding risk factors, and the risk and benefits of hemostatic interventions in patients with cirrhosis. We provide guidance recommendations on evaluating bleeding risk in this patient group and management of hemostatic abnormalities in the periprocedural setting.
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Affiliation(s)
- Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, UK
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre (Haematology), Oxford, UK
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, IDIBAPS, Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), University of Barcelona, Barcelona, Spain
| | - Maria Magnusson
- Department of Pediatrics, Clinical Chemistry and Blood Coagulation Research, MMK, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | - Armando Tripodi
- IRCCS Ca' Granda Maggiore Hospital Foundation, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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de Bruin S, Eggermont D, van Bruggen R, de Korte D, Scheeren TWL, Bakker J, Vlaar APJ. Transfusion practice in the bleeding critically ill: An international online survey-The TRACE-2 survey. Transfusion 2021; 62:324-335. [PMID: 34971005 PMCID: PMC9305497 DOI: 10.1111/trf.16789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 11/20/2021] [Accepted: 12/09/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transfusion is very common in the intensive care unit (ICU), but practice is highly variable, as has recently been shown in non-bleeding critically ill patients practices survey. Bleeding patients in ICU require different blood products across a range of specific patient categories. We hypothesize that a large variety in transfusion practice exists in bleeding patients. STUDY DESIGN AND METHODS An international online survey was performed among physicians working in the ICU. Transfusion practice in massively and non-massively bleeding patients was examined, including transfusion ratios, thresholds, and the presence of transfusion guidelines. RESULTS Six hundred eleven respondents filled in the survey of which 401 could be analyzed, representing 64 countries. Among the respondents, 52% had a massive transfusion protocol (MTP) available at their ICU. In massively bleeding patients, 46% of the respondents used fixed transfusion component ratios. Of those who used fixed blood ratios, the 1:1:1 ratio (red blood cell [RBC] concentrates: plasma: platelet concentrates) was most commonly used (33%). The presence of an MTP was associated with a more frequent use of fixed ratios (p < .001). For RBC transfusion in the general non-massively bleeding ICU population, a hemoglobin (Hb) threshold of 7.0[7.0-7.3] g/dl was reported. In the general ICU population, a platelet count threshold of 50[26-50] × 109 /L was applied. DISCUSSION Half of the centers had no massive transfusion protocol available. Transfusion practice in massively bleeding critically ill patients is highly variable and driven by the presence of an MTP. In the general non-massively bleeding ICU population restrictive transfusion triggers were chosen.
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Affiliation(s)
- Sanne de Bruin
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Department of Blood Cell Research, Sanquin Research, and Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Dorus Eggermont
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin Research, and Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Dirk de Korte
- Department of Blood Cell Research, Sanquin Research, and Landsteiner Laboratory, University of Amsterdam, Amsterdam, The Netherlands.,Department of Product and Process Development, Sanquin Blood Bank, Amsterdam, The Netherlands
| | - Thomas W L Scheeren
- Department of Anaesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan Bakker
- Department of Intensive Care Medicine, Erasmus MC University Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Department of Intensive Care Medicine, New York University Medical Center and Columbia University Medical Center New York, New York, New York, USA.,Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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125
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El-Menyar A, Ahmed K, Hakim S, Kanbar A, Mathradikkal S, Siddiqui T, Jogol H, Younis B, Taha I, Mahmood I, Ajaj A, Atique S, Alaieb A, Bahey AAA, Asim M, Alinier G, Castle NR, Mekkodathil A, Rizoli S, Al-Thani H. Efficacy and safety of the second in-hospital dose of tranexamic acid after receiving the prehospital dose: double-blind randomized controlled clinical trial in a level 1 trauma center. Eur J Trauma Emerg Surg 2021; 48:3089-3099. [PMID: 34910219 PMCID: PMC9360064 DOI: 10.1007/s00068-021-01848-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/23/2021] [Indexed: 11/29/2022]
Abstract
Background Prehospital administration of tranexamic acid (TXA) to injured patients is increasing worldwide. However, optimal TXA dose and need of a second infusion on hospital arrival remain undetermined. We investigated the efficacy and safety of the second in-hospital dose of TXA in injured patients receiving 1 g of TXA in the prehospital setting. We hypothesized that a second in-hospital dose of TXA improves survival of trauma patients. Methods A prospective, double-blind, placebo-controlled randomized, clinical trial included adult trauma patients receiving 1 g of TXA in the prehospital settings. Patients were then blindly randomized to Group I (second 1-g TXA) and Group II (placebo) on hospital arrival. The primary outcome was 24-h (early) and 28-day (late) mortality. Secondary outcomes were thromboembolic events, blood transfusions, hospital length of stay (HLOS) and organs failure (MOF). Results A total of 220 patients were enrolled, 110 in each group. The TXA and placebo groups had a similar early [OR 1.000 (0.062–16.192); p = 0.47] and late mortality [OR 0.476 (95% CI 0.157–1.442), p = 0.18].The cause of death (n = 15) was traumatic brain injury (TBI) in 12 patients and MOF in 3 patients. The need for blood transfusions in the first 24 h, number of transfused blood units, HLOS, thromboembolic events and multiorgan failure were comparable in the TXA and placebo groups. In seriously injured patients (injury severity score > 24), the MTP activation was higher in the placebo group (31.3% vs 11.10%, p = 0.13), whereas pulmonary embolism (6.9% vs 2.9%, p = 0.44) and late mortality (27.6% vs 14.3%, p = 0.17) were higher in the TXA group but did not reach statistical significance. Conclusion The second TXA dose did not change the mortality rate, need for blood transfusion, thromboembolic complications, organ failure and HLOS compared to a single prehospital dose and thus its routine administration should be revisited in larger and multicenter studies. Trial registration ClinicalTrials.gov Identifier: NCT03846973.
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Affiliation(s)
- Ayman El-Menyar
- Trauma & Vascular Surgery, Clinical Research, Hamad General Hospital, Hamad Medical Corporation (HMC), P.O Box 3050, Doha, Qatar. .,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Khalid Ahmed
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Suhail Hakim
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Ahad Kanbar
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Saji Mathradikkal
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Tariq Siddiqui
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Hisham Jogol
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Ibrahim Taha
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Ismail Mahmood
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Ahmed Ajaj
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Sajid Atique
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Abubaker Alaieb
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | | | - Mohammad Asim
- Trauma & Vascular Surgery, Clinical Research, Hamad General Hospital, Hamad Medical Corporation (HMC), P.O Box 3050, Doha, Qatar
| | - Guillaume Alinier
- Hamad Medical Corporation Ambulance Service, Medical City, HMC, Doha, Qatar.,Weill Cornell Medicine-Qatar, Doha, Qatar.,School of Health and Social Work, Paramedic Division, University of Hertfordshire, Hatfield, UK.,Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Nicholas R Castle
- Hamad Medical Corporation Ambulance Service, Medical City, HMC, Doha, Qatar
| | - Ahammed Mekkodathil
- Trauma & Vascular Surgery, Clinical Research, Hamad General Hospital, Hamad Medical Corporation (HMC), P.O Box 3050, Doha, Qatar
| | - Sandro Rizoli
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
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126
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Vlaar APJ, Dionne JC, de Bruin S, Wijnberge M, Raasveld SJ, van Baarle FEHP, Antonelli M, Aubron C, Duranteau J, Juffermans NP, Meier J, Murphy GJ, Abbasciano R, Müller MCA, Lance M, Nielsen ND, Schöchl H, Hunt BJ, Cecconi M, Oczkowski S. Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med 2021; 47:1368-1392. [PMID: 34677620 PMCID: PMC8532090 DOI: 10.1007/s00134-021-06531-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/04/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE To develop evidence-based clinical practice recommendations regarding transfusion practices and transfusion in bleeding critically ill adults. METHODS A taskforce involving 15 international experts and 2 methodologists used the GRADE approach to guideline development. The taskforce addressed three main topics: transfusion support in massively and non-massively bleeding critically ill patients (transfusion ratios, blood products, and point of care testing) and the use of tranexamic acid. The panel developed and answered structured guideline questions using population, intervention, comparison, and outcomes (PICO) format. RESULTS The taskforce generated 26 clinical practice recommendations (2 strong recommendations, 13 conditional recommendations, 11 no recommendation), and identified 10 PICOs with insufficient evidence to make a recommendation. CONCLUSIONS This clinical practice guideline provides evidence-based recommendations for the management of massively and non-massively bleeding critically ill adult patients and identifies areas where further research is needed.
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Affiliation(s)
- Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, Canada
- The Guidelines in Intensive Care Development and Evaluation (GUIDE) Group, He Research Institute St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Division of Gastroenterology, McMaster University, Hamilton, ON, Canada
| | - Sanne de Bruin
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marije Wijnberge
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - S Jorinde Raasveld
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Frank E H P van Baarle
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Massimo Antonelli
- Department of Anaesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
- Istituto di Anaesthesiology e Rianimazione Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cecile Aubron
- Department of Intensive Care Medicine, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Université de Bretagne Occidentale, Brest, France
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud (HUPS), Le Kremlin-Bicêtre, France
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- OLVG Hospital, Amsterdam, The Netherlands
| | - Jens Meier
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Kepler University, Linz, Austria
| | - Gavin J Murphy
- NIHR Leicester Biomedical Research Centre-Cardiovascular, Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Riccardo Abbasciano
- NIHR Leicester Biomedical Research Centre-Cardiovascular, Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marcus Lance
- Department of Anesthesiology, Intensive Care and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guys & St Thomas' NHS Foundation Trust, London, UK
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Centre-IRCCS, Rozzano, MI, Italy
- Humanitas University, via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- The Guidelines in Intensive Care Development and Evaluation (GUIDE) Group, He Research Institute St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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127
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Erasu V, Novak A. No role for tranexamic acid in the treatment of acute gastrointestinal bleeding. BMJ Evid Based Med 2021; 26:e9. [PMID: 33087453 DOI: 10.1136/bmjebm-2020-111498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Vishakha Erasu
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alex Novak
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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128
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Abstract
Fibrinogen plays a fundamental role in coagulation through its support for platelet aggregation and its conversion to fibrin. Fibrin stabilizes clots and serves as a scaffold and immune effector before being broken down by the fibrinolytic system. Given its importance, abnormalities in fibrin(ogen) and fibrinolysis result in a variety of disorders with hemorrhagic and thrombotic manifestations. This review summarizes (i) the basic elements of fibrin(ogen) and its role in coagulation and the fibrinolytic system; (ii) the laboratory evaluation for fibrin(ogen) disorders, including the use of global fibrinolysis assays; and (iii) the management of congenital and acquired disorders of fibrinogen and fibrinolysis.
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Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, University of Alabama at Birmingham, 1720 2nd Avenue South, NP 2503, Birmingham, AL 35294, USA
| | - Alisa S Wolberg
- UNC Department of Pathology and Laboratory Medicine, UNC Blood Research Center, 8018A Mary Ellen Jones Building, CB7035, Chapel Hill, NC 27599-7035, USA
| | - Ming Yeong Lim
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, 2000 Circle Hope Drive, Room 4126, Salt Lake City, UT 84112, USA.
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Analysis of the Effect of Intelligent Red Blood Cell Distribution Diagnosis Model on the Diagnosis and Treatment of Gastrointestinal Bleeding. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:5216979. [PMID: 34804453 PMCID: PMC8604600 DOI: 10.1155/2021/5216979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/06/2021] [Accepted: 10/23/2021] [Indexed: 02/08/2023]
Abstract
In order to explore the role of red blood cell distribution width in the diagnosis and treatment of gastrointestinal bleeding, this paper applies map feature recognition technology to red blood cell distribution broadband and constructs an intelligent red blood cell distribution width diagnosis model. To extract the content-level features of the image safely and effectively, this paper introduces the mechanism of jitter quantization to extract the content-level features at the lowest frequency of the image. In addition, this article employs an experimental approach to investigate the function of red blood cell distribution width in the diagnosis and management of gastrointestinal bleeding in the elderly. Finally, this article establishes an experimental group and a control group and then performs a research study using real-life hospital case studies. According to the statistical findings, the red blood cell distribution width index may play a significant role in the diagnosis and management of gastrointestinal bleeding, particularly in the case of severe bleeding.
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130
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Nguyen G, Lejeune M, Crichi B, Frere C. Hemostasis testing in patients with liver dysfunction: Advantages and caveats. World J Gastroenterol 2021; 27:7285-7298. [PMID: 34876789 PMCID: PMC8611202 DOI: 10.3748/wjg.v27.i42.7285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/08/2021] [Accepted: 10/20/2021] [Indexed: 02/06/2023] Open
Abstract
Due to concomitant changes in pro- and anti-coagulant mechanisms, patients with liver dysfunction have a “rebalanced hemostasis”, which can easily be tipped toward either a hypo- or a hypercoagulable phenotype. Clinicians are often faced with the question whether patients with chronic liver disease undergoing invasive procedures or surgery and those having active bleeding require correction of the hemostasis abnormalities. Conventional coagulation screening tests, such as the prothrombin time/international normalized ratio and the activated partial thromboplastin time have been demonstrated to have numerous limitations in these patients and do not predict the risk of bleeding prior to high-risk procedures. The introduction of global coagulation assays, such as viscoelastic testing (VET), has been an important step forward in the assessment of the overall hemostasis profile. A growing body of evidence now suggests that the use of VET might be of significant clinical utility to prevent unnecessary infusion of blood products and to improve outcomes in numerous settings. The present review discusses the advantages and caveats of both conventional and global coagulation assays to assess the risk of bleeding in patients with chronic liver disease as well as the current role of transfusion and hemostatic agents to prevent or manage bleeding.
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Affiliation(s)
- Guillaume Nguyen
- Department of Hematology, Trousseau Hospital, Assistance Publique Hôpitaux de Paris, Paris 75012, France
| | - Manon Lejeune
- Department of Hematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris 75013, France
| | - Benjamin Crichi
- Department of Internal Medicine, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, Paris 75010, France
| | - Corinne Frere
- Department of Hematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris 75013, France
- Inserm UMRS_1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris 75013, France
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131
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Koh A, Adiamah A, Gomez D, Sanyal S. Safety and Efficacy of Tranexamic Acid to Minimise Perioperative Bleeding in Hepatic Surgery: A Systematic Review and Meta-Analysis. World J Surg 2021; 46:441-449. [PMID: 34762141 DOI: 10.1007/s00268-021-06355-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Perioperative bleeding poses a major risk during liver surgery, which can result in increased transfusion requirements, morbidity, and mortality. Tranexamic acid (TXA) effectively reduces perioperative bleeding and transfusion requirements in trauma patients. However, there remains a lack of evidence of its use in liver surgery. This meta-analysis of randomised controlled trials evaluated the efficacy and safety of TXA in liver resection and transplantation. METHOD A comprehensive search of Medline, Embase, CENTRAL and Clinicaltrials.gov databases was undertaken to identify studies from January 1947 to September 2021. The outcomes of the need for blood transfusion, thromboembolic events and mortality were extracted from the included studies. Quantitative pooling of data was based on the random effects model. RESULTS Six studies reporting on 429 patients were included. TXA reduced the need for perioperative blood transfusion in liver resection and transplantation (OR 0.09; 95% CI 0.01 to 0.72). More importantly, TXA did not increase the incidence of thromboembolic events (OR 2.22; 95% CI 0.47 to 10.43) and mortality (OR 0.60; 95% CI 0.13 to 2.76). CONCLUSION TXA safely reduces the need for blood transfusion in patients undergoing liver resection and transplantation.
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Affiliation(s)
- Amanda Koh
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Alfred Adiamah
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Dhanwant Gomez
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Sudip Sanyal
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK.
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132
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Murao S, Nakata H, Roberts I, Yamakawa K. Effect of tranexamic acid on thrombotic events and seizures in bleeding patients: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:380. [PMID: 34724964 PMCID: PMC8561958 DOI: 10.1186/s13054-021-03799-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/21/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) reduces surgical bleeding and reduces death from bleeding after trauma and childbirth. However, its effects on thrombotic events and seizures are less clear. We conducted a systematic review and meta-analysis to examine the safety of TXA in bleeding patients. METHODS For this systematic review and meta-analysis, we searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled trials from inception until June 1, 2020. We included randomized trials comparing intravenous tranexamic acid and placebo or no intervention in bleeding patients. The primary outcomes were thrombotic events, venous thromboembolism, acute coronary syndrome, stroke and seizures. A meta-analysis was performed using a random effects model and meta-regression analysis was performed to evaluate how effects vary by dose. We assessed the certainty of evidence using the grading of recommendations, assessment, development and evaluations (GRADE) approach. RESULTS A total of 234 studies with 102,681 patients were included in the meta-analysis. In bleeding patients, there was no evidence that TXA increased the risk of thrombotic events (RR = 1.00 [95% CI 0.93-1.08]), seizures (1.18 [0.91-1.53]), venous thromboembolism (1.04 [0.92-1.17]), acute coronary syndrome (0.88 [0.78-1.00]) or stroke (1.12 [0.98-1.27]). In a dose-by-dose sensitivity analysis, seizures were increased in patients receiving more than 2 g/day of TXA (3.05 [1.01-9.20]). Meta-regression showed an increased risk of seizures with increased dose of TXA (p = 0.011). CONCLUSION Tranexamic acid did not appear to increase the risk of thrombotic events in bleeding patients. However, because there may be dose-dependent increase in the risk of seizures, very high doses should be avoided.
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Affiliation(s)
- Shuhei Murao
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Hidekazu Nakata
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi, Osaka, 558-8558, Japan
| | - Ian Roberts
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, 2-7 Daigakumachi, Takatsuki, Osaka, 569-8686, Japan.
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133
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Roberts I, Shakur-Still H, Afolabi A, Akere A, Arribas M, Austin E, Bal K, Bazeer N, Beaumont D, Brenner A, Carrington L, Chaudhri R, Coats T, Gilmore I, Halligan K, Hussain I, Jairath V, Javaid K, Kayani A, Lisman T, Mansukhani R, Miners A, Mutti M, Nadeem MA, Pollok R, Prowse D, Simmons J, Stanworth S, Veitch A, Williams J. A high-dose 24-hour tranexamic acid infusion for the treatment of significant gastrointestinal bleeding: HALT-IT RCT. Health Technol Assess 2021; 25:1-86. [PMID: 34663491 DOI: 10.3310/hta25580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Tranexamic acid reduces blood loss in surgery and the risk of death in trauma patients. Meta-analyses of small trials suggest that tranexamic acid decreases the number of deaths from gastrointestinal bleeding, but these meta-analyses are prone to selection bias. OBJECTIVE The trial provides reliable evidence of the effect of tranexamic acid on mortality, rebleeding and complications in significant acute gastrointestinal bleeding. DESIGN A multicentre, randomised, placebo-controlled trial and economic analysis. Patients were assigned by selecting one treatment pack from a box of eight, which were identical apart from the pack number. Patients, caregivers and outcome assessors were masked to allocation. The main analyses were by intention to treat. SETTING The setting was 164 hospitals in 15 countries, co-ordinated from the London School of Hygiene & Tropical Medicine. PARTICIPANTS Adults with significant upper or lower gastrointestinal bleeding (n = 12,009) were eligible if the responsible clinician was substantially uncertain about whether or not to use tranexamic acid. The clinical diagnosis of significant bleeding implied a risk of bleeding to death, including hypotension, tachycardia or signs of shock, or urgent transfusion, endoscopy or surgery. INTERVENTION Tranexamic acid (a 1-g loading dose over 10 minutes, then a 3-g maintenance dose over 24 hours) or matching placebo. MAIN OUTCOME MEASURES The primary outcome was death due to bleeding within 5 days of randomisation. Secondary outcomes were all-cause and cause-specific mortality; rebleeding; need for endoscopy, surgery or radiological intervention; blood product transfusion; complications; disability; and days spent in intensive care or a high-dependency unit. RESULTS A total of 12,009 patients were allocated to receive tranexamic acid (n = 5994, 49.9%) or the matching placebo (n = 6015, 50.1%), of whom 11,952 (99.5%) received the first dose. Death due to bleeding within 5 days of randomisation occurred in 222 (3.7%) patients in the tranexamic acid group and in 226 (3.8%) patients in the placebo group (risk ratio 0.99, 95% confidence interval 0.82 to 1.18). Thromboembolic events occurred in 86 (1.4%) patients in the tranexamic acid group and 72 (1.2%) patients in the placebo group (risk ratio 1.20, 95% confidence interval 0.88 to 1.64). The risk of arterial thromboembolic events (myocardial infarction or stroke) was similar in both groups (0.7% in the tranexamic acid group vs. 0.8% in the placebo group; risk ratio 0.92, 95% confidence interval 0.60 to 1.39), but the risk of venous thromboembolic events (deep-vein thrombosis or pulmonary embolism) was higher in tranexamic acid-treated patients than in placebo-treated patients (0.8% vs. 0.4%; risk ratio 1.85, 95% confidence interval 1.15 to 2.98). Seizures occurred in 38 patients who received tranexamic acid and in 22 patients who received placebo (0.6% vs. 0.4%, respectively; risk ratio 1.73, 95% confidence interval 1.03 to 2.93). In the base-case economic analysis, tranexamic acid was not cost-effective and resulted in slightly poorer health outcomes than no tranexamic acid. CONCLUSIONS Tranexamic acid did not reduce death from gastrointestinal bleeding and, although inexpensive, it is not cost-effective in adults with acute gastrointestinal bleeding. FUTURE WORK These results caution against a uniform approach to the management of patients with major haemorrhage and highlight the need for randomised trials targeted at specific pathophysiological processes. LIMITATIONS Although this is one of the largest randomised trials in gastrointestinal bleeding, we cannot rule out a modest increase or decrease in death due to bleeding with tranexamic acid. TRIAL REGISTRATION Current Controlled Trials ISRCTN11225767, ClinicalTrials.gov NCT01658124 and EudraCT 2012-003192-19. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 58. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Adefemi Afolabi
- Department of Surgery, University College Hospital Ibadan, Ibadan, Nigeria
| | - Adegboyega Akere
- Department of Medicine, University College Hospital Ibadan, Ibadan, Nigeria
| | - Monica Arribas
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Austin
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Kiran Bal
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Nuha Bazeer
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.,Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Danielle Beaumont
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Amy Brenner
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Laura Carrington
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Rizwana Chaudhri
- Department of Obstetrics and Gynaecology, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Timothy Coats
- Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Ian Gilmore
- Liverpool Centre for Alcohol Research, University of Liverpool, Liverpool, UK
| | | | - Irshad Hussain
- Department of Medicine, King Edward Medical University, Mayo Hospital, Lahore, Pakistan
| | - Vipul Jairath
- Division of Gastroenterology, Western University and London Health Sciences Centre, London, ON, Canada
| | - Kiran Javaid
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Aasia Kayani
- Rawalpindi Medical University - Pakistan National Coordinating Centre (RMU-PNCC), Rawalpindi, Pakistan
| | - Ton Lisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Raoul Mansukhani
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Muttiullah Mutti
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Muhammad Arif Nadeem
- Medical Unit III, Services Institute of Medical Sciences, Services Hospital Gastrointestinal, Lahore, Pakistan
| | - Richard Pollok
- Gastroenterology and Hepatology Department, St George's Hospital, London, UK
| | - Danielle Prowse
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Jonathan Simmons
- Gastroenterology Department, Royal Berkshire Hospital, Reading, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), John Radcliffe Hospital, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Andrew Veitch
- Gastroenterology Department, New Cross Hospital, Wolverhampton, UK
| | - Jack Williams
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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134
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Stanworth S, Callum J. The Paradox of Choice in Hemostatic Resuscitation: Still More Options Than Evidence, But a Good Start. Transfus Med Rev 2021; 35:71-72. [PMID: 34598875 DOI: 10.1016/j.tmrv.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), Oxford, United Kingdom; Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada.
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135
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Korytny A, Klein A, Marcusohn E, Freund Y, Neuberger A, Raz A, Miller A, Epstein D. Hypocalcemia is associated with adverse clinical course in patients with upper gastrointestinal bleeding. Intern Emerg Med 2021; 16:1813-1822. [PMID: 33651325 DOI: 10.1007/s11739-021-02671-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/11/2021] [Indexed: 12/26/2022]
Abstract
Acute non-variceal upper gastrointestinal bleeding (NV-UGIB) is associated with significant morbidity and mortality. Early and efficient risk stratification can facilitate management and improve outcomes. We aimed to determine whether the level of ionized calcium (Ca++), an essential co-factor in the coagulation cascade, is associated with the severity of bleeding and the need for advanced interventions among these patients. This was a retrospective single-center cohort study of all patients admitted due to NV-UGIB. The primary outcome was transfusion of ≥ 2 packed red blood cells, arterial embolization, or emergency surgery. Secondary outcomes included (1) transfusion of ≥ 2 packed red blood cells, (2) arterial embolization, or emergency surgery, and (3) all-cause in-hospital mortality. Multivariable logistic regression was performed to determine whether Ca++ was an independent predictor of these adverse outcomes. 1345 patients were included. Hypocalcemia was recorded in 604 (44.9%) patients. The rates of primary adverse outcome were significantly higher in the hypocalcemic group, 14.4% vs. 5.1%, p < 0.001. Secondary outcomes-multiple transfusions, need for angiography or surgery, and mortality were also increased (9.9% vs. 2.3%, p < 0.001, 5.3% vs. 2.8%, p = 0.03, and 33.3% vs. 24.7%, p < 0.001, respectively). Hypocalcemia was an independent predictor of primary and all the secondary outcomes, except mortality. Hypocalcemia in high-risk hospitalized patients with NV-UGIB is common and independently associated with adverse outcomes. Ca++ monitoring in this population may facilitate the rapid identification of high-risk patients. Trials are needed to assess whether correction of hypocalcemia will lead to improved outcomes.
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Affiliation(s)
- Alexander Korytny
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Amir Klein
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Erez Marcusohn
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Yaacov Freund
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Ami Neuberger
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
- Department of Internal Medicine "B", Rambam Health Care Campus, Haifa, Israel
| | - Aeyal Raz
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
- Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel
| | - Asaf Miller
- Medical Intensive Care Unit, Rambam Health Care Campus, Haifa, Israel
| | - Danny Epstein
- Critical Care Division, Rambam Health Care Campus, HaAliya HaShniya St. 8, 3109601, Haifa, Israel.
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136
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Braun G. [Management of bleeding in patients on antithrombotic therapy]. Med Klin Intensivmed Notfmed 2021; 116:491-498. [PMID: 34463792 DOI: 10.1007/s00063-021-00848-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/24/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Severe bleeding under antithrombotic therapy is common and challenging in intensive care medicine; on the one hand, rapid bleeding control must be achieved and, on the other hand, thromboembolic complications must be avoided. AIMS The paper will provide a brief overview of direct oral anticoagulants, therapeutic options and precise instructions for dealing with severe bleeding. RESULTS In addition to general measures in direct oral anticoagulant (DOAC)-associated major bleeding, prothrombin complex concentrate (PCC), idarucizumab and andexanet alfa are available as specific antidote therapy. In case of bleeding under heparin therapy, protamine sulfate is available as a possible antidote. CONCLUSIONS In particular, the importance of andexanet alfa in the treatment of factor Xa inhibitor-associated bleeding requires further investigation.
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Affiliation(s)
- Georg Braun
- Intensivzentrum, Medizinische Klinik 3 am Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
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137
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Allen ES, Cohn CS, Bakhtary S, Dunbar NM, Gniadek T, Hopkins CK, Jacobson J, Lokhandwala PM, Metcalf RA, Murphy C, Prochaska MT, Raval JS, Shan H, Storch EK, Pagano MB. Current advances in transfusion medicine 2020: A critical review of selected topics by the AABB Clinical Transfusion Medicine Committee. Transfusion 2021; 61:2756-2767. [PMID: 34423446 DOI: 10.1111/trf.16625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/19/2021] [Accepted: 07/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The AABB Clinical Transfusion Medicine Committee (CTMC) compiles an annual synopsis of the published literature covering important developments in the field of transfusion medicine (TM), which has been made available as a manuscript published in Transfusion since 2018. METHODS CTMC committee members reviewed original manuscripts including TM-related topics published electronically (ahead) or in print from December 2019 to December 2020. The selection of topics and manuscripts was discussed at committee meetings and chosen based on relevance and originality. Next, committee members worked in pairs to create a synopsis of each topic, which was then reviewed by two additional committee members. The first and senior authors of this manuscript assembled the final manuscript. Although this synopsis is extensive, it is not exhaustive, and some papers may have been excluded or missed. RESULTS The following topics are included: COVID-19 effects on the blood supply and regulatory landscape, COVID convalescent plasma, adult transfusion practices, whole blood, molecular immunohematology, pediatric TM, cellular therapy, and apheresis medicine. CONCLUSIONS This synopsis provides easy access to relevant topics and may be useful as an educational tool.
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Affiliation(s)
- Elizabeth S Allen
- Department of Pathology, University of California San Diego, La Jolla, California, USA
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sara Bakhtary
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Nancy M Dunbar
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Thomas Gniadek
- Department of Pathology, NorthShore University Health System, Chicago, Illinois, USA
| | | | - Jessica Jacobson
- Department of Pathology, New York University Grossman School of Medicine, New York, New York, USA
| | - Parvez M Lokhandwala
- American Red Cross, Biomedical Services, Baltimore, Maryland, USA.,Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan A Metcalf
- Clinical Pathology Division, Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Colin Murphy
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Micah T Prochaska
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Hua Shan
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Emily K Storch
- Office of Blood Research and Review, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Monica B Pagano
- Transfusion Medicine Division, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
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138
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Ockerman A, Vanassche T, Garip M, Vandenbriele C, Engelen MM, Martens J, Politis C, Jacobs R, Verhamme P. Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review. Thromb J 2021; 19:54. [PMID: 34380507 PMCID: PMC8356407 DOI: 10.1186/s12959-021-00303-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We review the evidence for tranexamic acid (TXA) for the treatment and prevention of bleeding caused by surgery, trauma and bleeding disorders. We highlight therapeutic areas where evidence is lacking and discuss safety issues, particularly the concern regarding thrombotic complications. METHODS An electronic search was performed in PubMed and the Cochrane Library to identify clinical trials, safety reports and review articles. FINDINGS TXA reduces bleeding in patients with menorrhagia, and in patients undergoing caesarian section, myomectomy, hysterectomy, orthopedic surgery, cardiac surgery, orthognathic surgery, rhinoplasty, and prostate surgery. For dental extractions in patients with bleeding disorders or taking antithrombotic drugs, as well as in cases of idiopathic epistaxis, tonsillectomy, liver transplantation and resection, nephrolithotomy, skin cancer surgery, burn wounds and skin grafting, there is moderate evidence that TXA is effective for reducing bleeding. TXA was not effective in reducing bleeding in traumatic brain injury and upper and lower gastrointestinal bleeding. TXA reduces mortality in patients suffering from trauma and postpartum hemorrhage. For many of these indications, there is no consensus about the optimal TXA dose. With certain dosages and with certain indications TXA can cause harm, such as an increased risk of seizures after high TXA doses with brain injury and cardiac surgery, and an increased mortality after delayed administration of TXA for trauma events or postpartum hemorrhage. Whereas most trials did not signal an increased risk for thrombotic events, some trials reported an increased rate of thrombotic complications with the use of TXA for gastro-intestinal bleeding and trauma. CONCLUSIONS TXA has well-documented beneficial effects in many clinical indications. Identifying these indications and the optimal dose and timing to minimize risk of seizures or thromboembolic events is work in progress.
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Affiliation(s)
- Anna Ockerman
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium.
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Melisa Garip
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Jeroen Martens
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Verhamme
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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Abstract
OBJECTIVE Evidence-based medicine was used to evaluate the efficacy and safety of tranexamic acid in patients with intracerebral hemorrhage. METHODS Pubmed (MEDLINE), Embase, and Cochrane Library were searched from January 2001 to October 2020 for randomized controlled trials (RCTs), cohort studies, and retrospective case series .The Jadad scale and RevMan software version 5.3 were used for literature quality assessment and meta-analysis. RESULTS In total, 4 randomized controlled trials and 1 retrospective case series with 2808 participants were included in the meta-analysis. Compared with control intervention in intracerebral hemorrhage, tranexamic acid could significantly reduce growth of hemorrhagic mass (odds ratio (OR) =0.81; 95% confidence interval(CI)=0.68 to 0.99; p = 0.04) and Modified Rankin Scale score (MRS) at 90 days at 0-3 (OR = 1.20; 95% CI = 1.00 to 1.43; p = 0.05), mortality by day 90 (OR= 1.03; 95% CI= 0.85-1.25; p = 0.77) and major thromboembolic events (OR= 1.14; 95% CI= 0.73-1.77; p = 0.58). CONCLUSIONS Treatment with tranexamic acid could reduce hematoma expansion in intracerebral hemorrhage, and the treatment was safe with no increase in thromboembolic complications. But showed no notable impact on good functional outcomes and mortality.
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Affiliation(s)
- Zhang Yu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Department of Neurology, Chengdu Shangjin Nanfu Hospital, Chengdu, Sichuan, China
| | - Liu Ling
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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140
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Imach S, Wafaisade A, Lefering R, Böhmer A, Schieren M, Suárez V, Fröhlich M. The impact of prehospital tranexamic acid on mortality and transfusion requirements: match-pair analysis from the nationwide German TraumaRegister DGU®. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:277. [PMID: 34348782 PMCID: PMC8336395 DOI: 10.1186/s13054-021-03701-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/20/2021] [Indexed: 12/14/2022]
Abstract
Background Outcome data about the use of tranexamic acid (TXA) in civilian patients in mature trauma systems are scarce. The aim of this study was to determine how severely injured patients are affected by the widespread prehospital use of TXA in Germany. Methods The international TraumaRegister DGU® was retrospectively analyzed for severely injured patients with risk of bleeding (2015 until 2019) treated with at least one dose of TXA in the prehospital phase (TXA group). These were matched with patients who had not received prehospital TXA (control group), applying propensity score-based matching. Adult patients (≥ 16) admitted to a trauma center in Germany with an Injury Severity Score (ISS) ≥ 9 points were included. Results The matching yielded two comparable cohorts (n = 2275 in each group), and the mean ISS was 32.4 ± 14.7 in TXA group vs. 32.0 ± 14.5 in control group (p = 0.378). Around a third in both groups received one dose of TXA after hospital admission. TXA patients were significantly more transfused (p = 0.022), but needed significantly less packed red blood cells (p ≤ 0.001) and fresh frozen plasma (p = 0.023), when transfused. Massive transfusion rate was significantly lower in the TXA group (5.5% versus 7.2%, p = 0.015). Mortality was similar except for early mortality after 6 h (p = 0.004) and 12 h (p = 0.045). Among non-survivors hemorrhage as leading cause of death was less in the TXA group (3.0% vs. 4.3%, p = 0.021). Thromboembolic events were not significantly different between both groups (TXA 6.1%, control 4.9%, p = 0.080). Conclusion This is the largest civilian study in which the effect of prehospital TXA use in a mature trauma system has been examined. TXA use in severely injured patients was associated with a significantly lower risk of massive transfusion and lower mortality in the early in-hospital treatment period. Due to repetitive administration, a dose-dependent effect of TXA must be discussed.
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Affiliation(s)
- Sebastian Imach
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany.
| | - Arasch Wafaisade
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Andreas Böhmer
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Mark Schieren
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Victor Suárez
- Department II of Internal Medicine (Nephrology, Rheumatology, Diabetes and General Internal Medicine) and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Matthias Fröhlich
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
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Johnson-Arbor K, Verstraete R. Bloodless Management of the Anemic Patient in the Emergency Department. Ann Emerg Med 2021; 79:48-57. [PMID: 34353645 DOI: 10.1016/j.annemergmed.2021.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/26/2021] [Accepted: 06/14/2021] [Indexed: 11/16/2022]
Abstract
Anemia is a commonly encountered condition in emergency medicine; transfusion of packed red blood cells is commonly performed for anemic patients in the emergency department (ED), but some patients are unable to accept transfusion of blood products due to medical or religious concerns. The unique, acute, and time-sensitive nature of emergency medicine practice requires that physicians maintain an enhanced awareness of bloodless medicine treatment modalities. Identification of bloodless medicine patient preferences in the ED can help guide physicians in the recommendation of acceptable methods of treating anemia in this patient population. A focus on early hemostasis and resuscitation, instead of attempts to convince the patient to accept blood transfusion, can be lifesaving in patients with acute bleeding. Treatment strategies including the use of methods to reduce unnecessary blood loss, enhance red blood cell production, and increase the oxygen-carrying capacity of blood should also be considered early in patient presentation. Timely involvement of the Hospital Liaison Committee can help facilitate successful interpersonal communication and shared decisionmaking between emergency physicians and bloodless medicine patients. By embracing an understanding of bloodless medicine patient needs as well as available treatment strategies, ED physicians can contribute to optimal overall outcomes for anemic bloodless medicine patients.
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Affiliation(s)
- Kelly Johnson-Arbor
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC; MedStar Institute for Quality and Safety, MedStar Health, Columbia, MD.
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Lin YC, Chen CY, Chang CC, Kang YN. Letter: is there no conclusive evidence for the effect of tranexamic acid on mortality in gastrointestinal bleeding? Aliment Pharmacol Ther 2021; 54:523-525. [PMID: 34331803 DOI: 10.1111/apt.16502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Yu-Ci Lin
- Taipei Medical University, Taipei, Taiwan
| | | | - Chun-Chao Chang
- Taipei Medical University, Taipei, Taiwan.,Taipei Medical University Hospital, Taipei, Taiwan
| | - Yi-No Kang
- Taipei Medical University, Taipei, Taiwan.,Taipei Medical University Hospital, Taipei, Taiwan.,Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,National Taiwan University, Taipei, Taiwan
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143
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Triantafyllou K, Gkolfakis P, Gralnek IM, Oakland K, Manes G, Radaelli F, Awadie H, Camus Duboc M, Christodoulou D, Fedorov E, Guy RJ, Hollenbach M, Ibrahim M, Neeman Z, Regge D, Rodriguez de Santiago E, Tham TC, Thelin-Schmidt P, van Hooft JE. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:850-868. [PMID: 34062566 DOI: 10.1055/a-1496-8969] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
1: ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.Strong recommendation, low quality evidence. 2 : ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of ≤ 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.Strong recommendation, moderate quality evidence. 3 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7-9 g/dL is desirable.Strong recommendation, low quality evidence. 4 : ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of ≤ 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of ≥ 10 g/dL is desirable.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.Strong recommendation, low quality of evidence. 6 : ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.Strong recommendation, low quality evidence. 7 : ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.Strong recommendation, low quality evidence. 8 : ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.Strong recommendation, low quality evidence. 9: ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.Strong recommendation, moderate quality evidence. 10: ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.Strong recommendation, low quality evidence.
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Affiliation(s)
- Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare, London, UK
| | - Gianpiero Manes
- Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese and Rho, Milan, Italy
| | | | - Halim Awadie
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Marine Camus Duboc
- Gastroenterology Department, Saint-Antoine Hospital, APHP Sorbonne University, Paris, France
| | - Dimitrios Christodoulou
- Division of Gastroenterology, University Hospital & Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Evgeny Fedorov
- Department of Gastroenterology, Moscow University Hospital, Pirogov Russia National Research Medical University, Moscow, Russia
| | - Richard J Guy
- Department of Emergency General Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Marcus Hollenbach
- Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, Leipzig, Germany
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Ziv Neeman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Daniele Regge
- Radiology Unit, Candiolo Cancer Institute, FPO-IRCCS, Candiolo.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Spain
| | - Tony C Tham
- Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Peter Thelin-Schmidt
- Department of Medicine (Solna), Karolinska Institute and Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Lisman T, Procopet B. Fresh frozen plasma in treating acute variceal bleeding: Not effective and likely harmful. Liver Int 2021; 41:1710-1712. [PMID: 34273225 DOI: 10.1111/liv.14988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/04/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Bogdan Procopet
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania
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145
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Birda CL, Kumar A, Samanta J. Endotherapy for Nonvariceal Upper Gastrointestinal Hemorrhage. JOURNAL OF DIGESTIVE ENDOSCOPY 2021. [DOI: 10.1055/s-0041-1731962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AbstractNonvariceal upper gastrointestinal hemorrhage (NVUGIH) is a common GI emergency with significant morbidity and mortality. Triaging cases on the basis of patient-related factors, restrictive blood transfusion strategy, and hemodynamic stabilization are key initial steps for the management of patients with NVUGIH. Endoscopy remains a vital step for both diagnosis and definitive management. Multiple studies and guidelines have now defined the optimum timing for performing the endoscopy after hospitalization, to better the outcome. Conventional methods for achieving endoscopic hemostasis, such as injection therapy, contact, and noncontact thermal therapy, and mechanical therapy, such as through-the-scope clips, have reported to have 76 to 90% efficacy for primary hemostasis. Newer modalities to enhance hemostasis rates have come in vogue. Many of these modalities, such as cap-mounted clips, coagulation forceps, and hemostatic powders have proved to be efficacious in multiple studies. Thus, the newer modalities are recommended not only for management of persistent bleed and recurrent bleed after failed initial hemostasis, using conventional modalities but also now being advocated for primary hemostasis. Failure of endotherapy would warrant radiological or surgical intervention. Some newer tools to optimize endotherapy, such as endoscopic Doppler probes, for determining flow in visible or underlying vessels in ulcer bleed are now being evaluated. This review is focused on the technical aspects and efficacy of various endoscopic modalities, both conventional and new. A synopsis of the various studies describing and comparing the modalities have been outlined. Postendoscopic management including Helicobacter pylori therapy and starting of anticoagulants and antiplatelets have also been outlined.
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Affiliation(s)
- Chhagan L. Birda
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Antriksh Kumar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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146
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Dietrich M, Beynon C, Fiedler MO, Bernhard M, Kümpers P, Hecker A, Jungk C, Nusshag C, Michalski D, Brenner T, Weigand MA, Reuß CJ. [Focus general intensive care medicine. Intensive care studies from 2020/2021]. Anaesthesist 2021; 70:888-894. [PMID: 34324037 PMCID: PMC8319701 DOI: 10.1007/s00101-021-00976-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 11/26/2022]
Affiliation(s)
- M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - P Kümpers
- Klinik für Allg. Innere Medizin und Notaufnahme sowie Nieren- und Hochdruckkrankheiten und Rheumatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - A Hecker
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
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Bouillon-Minois JB, Croizier C, Baker JS, Pereira B, Moustafa F, Outrey J, Schmidt J, Peschanski N, Dutheil F. Tranexamic acid in non-traumatic intracranial bleeding: a systematic review and meta-analysis. Sci Rep 2021; 11:15275. [PMID: 34315966 PMCID: PMC8316462 DOI: 10.1038/s41598-021-94727-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/08/2021] [Indexed: 02/07/2023] Open
Abstract
Non-traumatic intracranial bleeding (NTIB), comprising subarachnoid hemorrhage (SAH) and intra-cranial bleeding (ICH) is a significant public health concern. Tranexamic acid (TXA) is a promising treatment with benefits yet to be fully demonstrated. We conducted a systematic review and meta-analysis on the impact of TXA on mortality in NTIB. We searched the PubMed, Cochrane Library, Google Scholar and ScienceDirect databases for studies reporting mortality data following the use of TXA in NTIB for comparisons with a control group. We computed random-effect meta-analysis on estimates of risk and sensitivity analyses. We computed meta-regression to examine the putative effects of the severity of NTIB, sociodemographic data (age, sex), and publication date. Among potentially 10,008 articles, we included 15 studies representing a total of 4883 patients: 2455 receiving TXA and 2428 controls; 1110 died (23%) during the follow-up. The meta-analysis demonstrated a potential of 22% decrease in mortality for patients treated by TXA (RR = 0.78, 95%CI 0.58-0.98, p = 0.002). Meta-regression did not demonstrate any influence of the severity of NTIB, age, sex, length of treatment or date of publication. Sensitivity analyses confirmed benefits of TXA on mortality. TXA appears to be a therapeutic option to reduce non-traumatic intracranial bleeding mortality, particularly in patients with SAH.
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Affiliation(s)
- Jean-Baptiste Bouillon-Minois
- grid.494717.80000000115480420CNRS, LaPSCo, Physiological and Psychosocial Stress, CHU Clermont–Ferrand, Emergency Medicine, Université Clermont Auvergne, 63000 Clermont–Ferrand, France ,grid.411163.00000 0004 0639 4151Emergency Department, CHU Clermont-Ferrand, 58, Rue Montalembert, 63000 Clermont-Ferrand, France
| | - Carolyne Croizier
- grid.411163.00000 0004 0639 4151Department of Hematology and Cell Therapy, CHU Clermont–Ferrand, 63000 Clermont–Ferrand, France
| | - Julien S. Baker
- grid.221309.b0000 0004 1764 5980Centre for Health and Exercise Science Research, Department of Sport, Physical Education and Health, Hong Kong Baptist University, Kowloon Tong, Hong Kong
| | - Bruno Pereira
- grid.411163.00000 0004 0639 4151Clinical Research and Innovation Direction, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Farès Moustafa
- grid.411163.00000 0004 0639 4151Emergency Department, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Justin Outrey
- grid.411158.80000 0004 0638 9213Emergency Department, CHU de Besançon, Besançon, France
| | - Jeannot Schmidt
- grid.494717.80000000115480420CNRS, LaPSCo, Physiological and Psychosocial Stress, CHU Clermont–Ferrand, Emergency Medicine, Université Clermont Auvergne, 63000 Clermont–Ferrand, France
| | - Nicolas Peschanski
- grid.411154.40000 0001 2175 0984Emergency Department & SAMU, University of Rennes Hospital, 35000 Rennes, France ,grid.410368.80000 0001 2191 9284Rennes-1 University School of Medicine, 35000 Rennes, France
| | - Frédéric Dutheil
- grid.494717.80000000115480420CNRS, LaPSCo, Physiological and Psychosocial Stress, CHU Clermont–Ferrand, Occupational and Environmental Medicine, Université Clermont Auvergne, WittyFit, 63000 Clermont–Ferrand, France
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Cañamares-Orbís P, Lanas Arbeloa Á. New Trends and Advances in Non-Variceal Gastrointestinal Bleeding-Series II. J Clin Med 2021; 10:3045. [PMID: 34300211 PMCID: PMC8303152 DOI: 10.3390/jcm10143045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022] Open
Abstract
The gastrointestinal tract is a long tubular structure wherein any point in the mucosa along its entire length could be the source of a hemorrhage. Upper (esophagel and gastroduodenal) and lower (jejunum, ileum, and colon) gastrointestinal bleeding are common. Gastroduodenal and colonic bleeding are more frequent than bleeding from the small bowel, but nowadays the entire gastrointestinal tract can be explored endoscopically and bleeding lesions can be locally treated successfully to stop or prevent further bleeding. The extensive use of antiplatelet and anticoagulants drugs in cardiovascular patients is, at least in part, the cause of the increasing number of patients suffering from gastrointestinal bleeding. Patients with these conditions are usually older and more fragile because of their comorbidities. The correct management of antithrombotic drugs in cases of gastrointestinal bleeding is essential for a successful outcome for patients. The influence of the microbiome in the pathogenesis of small bowel bleeding is an example of the new data that are emerging as potential therapeutic target for bleeding prevention. This text summarizes the latest research and advances in all forms of acute gastrointestinal bleeding (i.e., upper, small bowel and lower). Diagnosis is approached, and medical, endoscopic or antithrombotic management are discussed in the text in an accessible and comprehensible way.
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Affiliation(s)
- Pablo Cañamares-Orbís
- Gastroenterology, Hepatology and Nutrition Unit, San Jorge University Hospital, 22004 Huesca, Spain
| | - Ángel Lanas Arbeloa
- IIS Aragón, CIBERehd, 50009 Zaragoza, Spain;
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, 50009 Zaragoza, Spain
- University of Zaragoza, 500009 Zaragoza, Spain
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Perioperative Tranexamic Acid for ACTH-Secreting Pituitary Adenomas: Implementation Protocol Results and Trial Prospectus. World Neurosurg 2021; 153:e359-e364. [PMID: 34229096 DOI: 10.1016/j.wneu.2021.06.111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Primary resection of adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma has become a front-line standard-of-care treatment for Cushing disease. However, surgical intervention can be challenging because of elevated blood pressure, as well as direct cortisol impacts on endothelial cells, vascular permeability, and tissue friability-potentially resulting in increased intraoperative bleeding. Tranexamic acid (TXA) is a well-studied, widely used intravenous hemostatic; however, the potential benefit during resection of ACTH-secreting pituitary adenoma is unstudied. The purpose of this study was to define an institutional protocol for perioperative administration of TXA in patients undergoing endoscopic endonasal approach for resection of ACTH-secreting pituitary adenoma, and to study the implementation of our novel protocol in a prospective fashion. METHODS Criteria for preoperative TXA were defined by age, medical history, and risk factors. Descriptive statistics were reported for all patients receiving perioperative TXA. RESULTS Thirty patients met inclusion criteria and underwent perioperative administration of TXA, using a standardized dosing protocol of a 10 mg/kg bolus in 30 minutes prior to incision, followed by maintenance infusion of 2 mg/kg/hour for the duration of the procedure. No incidence of myocardial infarction or postoperative thromboembolic events were noted. Subjective assessments indicated satisfaction with the patient selection protocol, and meaningful reduction in the extent of intraoperative bleeding. CONCLUSIONS Perioperative TXA represents a potentially efficacious approach for control of intraoperative bleeding during endonasal resection of ACTH-secreting tumors. Careful preoperative patient selection is emphasized, given the potential for thromboembolic complications; however, initial experience with our institutional protocol suggests a favorable risk/benefit profile when this treatment is applied judiciously.
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