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Westfall KM, Andrews J, Sadek E, Curtiss W, Hecht J. A multicenter study of DDAVP versus platelet transfusions for antiplatelet agent reversal in patients with traumatic brain injury. Neurol Sci 2024; 45:3325-3332. [PMID: 38353847 DOI: 10.1007/s10072-024-07379-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 01/30/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Antiplatelet agents have been shown to worsen outcomes following traumatic injury. Research on desmopressin (DDAVP) and platelet transfusion for antiplatelet reversal is limited. We aimed to evaluate the effect of these agents on patients taking pre-injury antiplatelet medications who experienced traumatic brain injury (TBI) after blunt trauma. METHODS This is a retrospective cohort study of adult trauma patients from 2014 to 2021 on aspirin and/or a P2Y12 inhibitor. Patients were stratified into groups based on if they received DDAVP, platelets, both agents, or neither. RESULTS Of 5525 included patients, 4696 (85.4%) were not reversed, 461 (8.4%) received platelets, 173 (3.1%) received DDAVP, and 172 (3.1%) received both reversals. There was no statistically significant difference in length of stay between, but patients who received platelets or both reversals were more likely to have hospital complications (p < 0.05), longer hospital length of stay (p < 0.001), and longer ICU length of stay (p < 0.001) compared to those who did not receive reversal. A subgroup analysis of patients with a head AIS of 4 or 5 confirmed these findings. CONCLUSIONS Patients who received platelets or both reversals had a longer length of hospital stay and length of ICU stay. It is difficult to recommend one treatment over another based on our results alone. Further studies are needed to help clarify the risks and benefits of reversal agents in this patient population.
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Affiliation(s)
| | - Jessica Andrews
- Department of Pharmacy, Trinity Health Ann Arbor, Ann Arbor, MI, USA
| | - Erin Sadek
- Department of Pharmacy, Trinity Health Ann Arbor, Ann Arbor, MI, USA
| | - William Curtiss
- Department of Surgery, Trinity Health Ann Arbor, Ann Arbor, MI, USA
| | - Jason Hecht
- Department of Pharmacy, Trinity Health Ann Arbor, Ann Arbor, MI, USA
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2
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Al Arashi W, Romano LGR, Leebeek FWG, Kruip MJHA, van Galen KPM, Turan O, Kadir RA, Cnossen MH. Desmopressin to prevent and treat bleeding in pregnant women with an inherited bleeding disorder: a systematic literature review. J Thromb Haemost 2024; 22:126-139. [PMID: 37778511 DOI: 10.1016/j.jtha.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/28/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Although desmopressin (DDAVP) is an accessible and inexpensive hemostatic drug, its use in pregnancy is still debated due to safety uncertainties. OBJECTIVES We aimed to review the safety and effectiveness of DDAVP in women with an inherited bleeding disorder during pregnancy and delivery. METHODS Databases were searched for articles up to July 25, 2022, reporting maternal and/or neonatal outcomes. PRISMA methodology for systematic reviews and meta-analyses was followed (PROSPERO CRD42022316490). RESULTS Fifty-three studies were included, comprising 273 pregnancies. Regarding maternal outcomes, DDAVP was administered in 73 women during pregnancy and in 232 during delivery. Safety outcome was reported in 245 pregnancies, with severe adverse events reported in 2 (1%, hyponatremia with neurologic symptoms). Overall, DDAVP was used as monotherapy in 234 pregnancies, with effectiveness reported in 153 pregnancies (82% effective; 18% ineffective). Regarding neonatal outcomes, out of 60 pregnancies with reported neonatal outcomes after DDAVP use during pregnancy, 2 children (3%) had a severe adverse event (preterm delivery n = 1; fetal growth restriction n = 1). Of the 232 deliveries, 169 neonates were exposed to DDAVP during delivery, and in 114 neonates, safety outcome was reported. Two children (2%) experienced a moderate adverse event (low Apgar score n = 1; transient hyperbilirubinemia not associated with DDAVP n = 1). CONCLUSION DDAVP use during pregnancy and delivery seems safe for the mother, with special attention to the occurrence of hyponatremia and for the child, especially during delivery. However, due to poor study designs and limited documentation of outcomes, a well-designed prospective study is warranted.
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Affiliation(s)
- Wala Al Arashi
- Department of Pediatric and Oncology Hematology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Lorenzo G R Romano
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Karin P M van Galen
- Center for Benign Hematology, Thrombosis and Hemostasis, van Creveldkliniek, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Ozlem Turan
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Foundation Hospital and Institute for Women's Health, University College London, London, UK
| | - Rezan Abdul Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Foundation Hospital and Institute for Women's Health, University College London, London, UK
| | - Marjon H Cnossen
- Department of Pediatric and Oncology Hematology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Theiler S, Hegetschweiler S, Staartjes VE, Spinello A, Brandi G, Regli L, Serra C. Influence of gender and sexual hormones on outcomes after pituitary surgery: a systematic review and meta-analysis. Acta Neurochir (Wien) 2023; 165:2445-2460. [PMID: 37555999 PMCID: PMC10477253 DOI: 10.1007/s00701-023-05726-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/07/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Although there is an increasing body of evidence showing gender differences in various medical domains as well as presentation and biology of pituitary adenoma (PA), gender differences regarding outcome of patients who underwent transsphenoidal resection of PA are poorly understood. The aim of this study was to identify gender differences in PA surgery. METHODS The PubMed/MEDLINE database was searched up to April 2023 to identify eligible articles. Quality appraisal and extraction were performed in duplicate. RESULTS A total of 40 studies including 4989 patients were included in this systematic review and meta-analysis. Our analysis showed odds ratio of postoperative biochemical remission in males vs. females of 0.83 (95% CI 0.59-1.15, P = 0.26), odds ratio of gross total resection in male vs. female patients of 0.68 (95% CI 0.34-1.39, P = 0.30), odds ratio of postoperative diabetes insipidus in male vs. female patients of 0.40 (95% CI 0.26-0.64, P < 0.0001), and a mean difference of preoperative level of prolactin in male vs. female patients of 11.62 (95% CI - 119.04-142.27, P = 0.86). CONCLUSIONS There was a significantly higher rate of postoperative DI in female patients after endoscopic or microscopic transsphenoidal PA surgery, and although there was some data in isolated studies suggesting influence of gender on postoperative biochemical remission, rate of GTR, and preoperative prolactin levels, these findings could not be confirmed in this meta-analysis and demonstrated no statistically significant effect. Further research is needed and future studies concerning PA surgery should report their data by gender or sexual hormones and ideally further assess their impact on PA surgery.
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Affiliation(s)
- Sven Theiler
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Saskia Hegetschweiler
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Antonio Spinello
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Giovanna Brandi
- Institute for Intensive Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Carlo Serra
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
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Romano LG, van Vulpen LF, den Exter PL, Heubel-Moenen FC, Hooijmeijer HL, Coppens M, Fijnvandraat K, Schols SE, Ypma PF, Smit C, Driessens MH, Rosendaal FR, van der Bom JG, Gouw SC, Kruip MJ. Desmopressin in nonsevere hemophilia A: patient perspectives on use and efficacy. Res Pract Thromb Haemost 2023; 7:100281. [PMID: 37601028 PMCID: PMC10439392 DOI: 10.1016/j.rpth.2023.100281] [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: 01/10/2023] [Revised: 05/22/2023] [Accepted: 06/01/2023] [Indexed: 08/22/2023] Open
Abstract
Background Desmopressin increases plasma factor VIII and von Willebrand factor levels in persons with nonsevere hemophilia A. Patients' perspectives on desmopressin are relevant to increase and optimize its suboptimal use. However, patients' views on desmopressin are not reported. Objectives To evaluate the perspectives of persons with nonsevere hemophilia A on desmopressin use, barriers for its use, side effects, and their knowledge about desmopressin's efficacy and side effects. Methods Persons with nonsevere hemophilia A were included in a cross-sectional, national, multicenter study. Questionnaires were filled out by adult patients and children aged ≥12 years themselves. Caretakers filled out questionnaires for children aged <12 years. Results In total, 706 persons with nonsevere hemophilia A were included (544 mild, 162 moderate, [age range, 0-88 years]). Of 508 patients, 234 (50%) patients reported previous desmopressin use. Desmopressin was considered as at least moderately effective in 171 of 187 (90%) patients. Intranasal administration was the modality of choice for 138 of 182 (76%) patients. Flushing was the most reported side effect in 54 of 206 (26%) adults and 7 of 22 (32%) children. The most frequently reported advantage and disadvantage were the convenience of intranasal, out-of-hospital administration by 56% (126/227) and side effects in 18% (41/227), respectively. Patients' self-perceived knowledge was unsatisfactory or unknown in 28% (63/225). Conclusion Overall, desmopressin was most often used intranasally and considered effective, with flushing as the most common side effect. The most mentioned advantage was the convenience of intranasal administration and disadvantage was side effects. More information and education on desmopressin could answer unmet needs in patients with current or future desmopressin treatment.
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Affiliation(s)
- Lorenzo G.R. Romano
- Department of Hematology, Hemophilia Treatment Center, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lize F.D. van Vulpen
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paul L. den Exter
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Helene L. Hooijmeijer
- Department of Pediatrics, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Amsterdam University Medical Center - Emma Children’s Hospital, University of Amsterdam, Amsterdam, The Netherlands
- Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Saskia E.M. Schols
- Department of Hematology, Radboud University Medical Center and Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
| | - Paula F. Ypma
- Department of Hematology, Haga Hospital, The Hague, The Netherlands
| | - Cees Smit
- Netherlands Hemophilia Patient Society (NVHP), Nijkerk, The Netherlands
| | | | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna G. van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Samantha C. Gouw
- Department of Pediatric Hematology, Amsterdam University Medical Center - Emma Children’s Hospital, University of Amsterdam, Amsterdam, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke J.H.A. Kruip
- Department of Hematology, Hemophilia Treatment Center, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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5
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Alrajhi AA, Alghamdi AS, Baali MH, Altowairqi AF, Khan MF, Alharthi AS, Albazee E, Abu-Zaid A. Efficacy of prophylactic pre-operative desmopressin administration during functional endoscopic sinus surgery for chronic rhinosinusitis: A systematic review and meta-analysis of randomised placebo-controlled trials. Clin Otolaryngol 2023; 48:139-150. [PMID: 36536598 DOI: 10.1111/coa.14020] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 12/03/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To examine the efficacy of prophylactic desmopressin versus placebo among patients undergoing functional endoscopic sinus surgery (FESS). DESIGN Systematic review and meta-analysis of randomised controlled trials (RCTs). SETTING The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Scopus, and Web of Science databases were screened from inception until 18 March 2022. PARTICIPANTS Patients undergoing FESS. MAIN OUTCOME MEASURES Primary efficacy endpoints comprised intraoperative blood loss, visual clarity, and operation time. Secondary endpoints comprised side effects. The efficacy endpoints were summarised as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). RESULTS Five RCTs comprising 380 patients (desmopressin = 191 patients and placebo = 189 patients) were included. Collectively, the included RCTs had an overall low risk of bias. The pooled results showed that the mean intraoperative blood loss (n = 5 RCTs, MD = -37.97 ml, 95% CI [-56.97, -18.96], p < .001), 5-point Boezaart scores (n = 2 RCTs, MD = -.97, 95% CI [-1.21, -.74], p < .001), and 10-point Boezaart scores (n = 2 RCTs, MD = -3.00, 95% CI [-3.61, -2.40], p < .001) were significantly reduced in favour of the desmopressin group compared with the placebo group. Operation time did not significantly differ between both groups (n = 5 RCTs, MD = -3.73 min, 95% CI [-14.65, 7.18], p = .50). No patient in both groups developed symptomatic hyponatremia (n = 3 RCTs, 194 patients) or thromboembolic events (n = 2 RCTs, 150 patients). CONCLUSIONS Among patients undergoing FESS, prophylactic administration of desmopressin does not correlate with significant clinical benefits. Data on safety is limited. Future research may explore the synergistic antihaemorrhagic efficacy and safety of tranexamic acid (TXA) plus desmopressin versus TXA alone among patients undergoing FESS.
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Affiliation(s)
- Abdullah Abdulaziz Alrajhi
- Department of Otolaryngology and Head and Neck Surgery, Al-Noor Specialist Hospital, Makkah, Saudi Arabia
| | - Abdullah Shakhs Alghamdi
- Department of Otolaryngology and Head and Neck Surgery, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Mohammed Hassan Baali
- Department of Otolaryngology and Head and Neck Surgery, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Abdulaziz Fahad Altowairqi
- Department of Otolaryngology and Head and Neck Surgery, King Abdulaziz Specialist Hospital, Taif, Saudi Arabia
| | - Meshal Fahad Khan
- Department of Otolaryngology and Head and Neck Surgery, Al-Noor Specialist Hospital, Makkah, Saudi Arabia
| | - Ahmad Saad Alharthi
- Department of Otolaryngology and Head and Neck Surgery, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Ebraheem Albazee
- Kuwait Institute for Medical Specializations, Kuwait City, Kuwait
| | - Ahmed Abu-Zaid
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.,College of Graduate Health Sciences, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Beverly A, Ong G, Kimber C, Sandercock J, Dorée C, Welton NJ, Wicks P, Estcourt LJ. Drugs to reduce bleeding and transfusion in major open vascular or endovascular surgery: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2023; 2:CD013649. [PMID: 36800489 PMCID: PMC9936832 DOI: 10.1002/14651858.cd013649.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
BACKGROUND Vascular surgery may be followed by internal bleeding due to inadequate surgical haemostasis, abnormal clotting, or surgical complications. Bleeding ranges from minor, with no transfusion requirement, to massive, requiring multiple blood product transfusions. There are a number of drugs, given systemically or applied locally, which may reduce the need for blood transfusion. OBJECTIVES To assess the effectiveness and safety of anti-fibrinolytic and haemostatic drugs and agents in reducing bleeding and the need for blood transfusion in people undergoing major vascular surgery or vascular procedures with a risk of moderate or severe (> 500 mL) blood loss. SEARCH METHODS We searched: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL, and Transfusion Evidence Library. We also searched the WHO ICTRP and ClinicalTrials.gov trial registries for ongoing and unpublished trials. Searches used a combination of MeSH and free text terms from database inception to 31 March 2022, without restriction on language or publication status. SELECTION CRITERIA We included randomised controlled trials (RCTs) in adults of drug treatments to reduce bleeding due to major vascular surgery or vascular procedures with a risk of moderate or severe blood loss, which used placebo, usual care or another drug regimen as control. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were units of red cells transfused and all-cause mortality. Our secondary outcomes included risk of receiving an allogeneic blood product, risk of reoperation or repeat procedure due to bleeding, risk of a thromboembolic event, risk of a serious adverse event and length of hospital stay. We used GRADE to assess certainty of evidence. MAIN RESULTS We included 22 RCTs with 3393 participants analysed, of which one RCT with 69 participants was reported only in abstract form, with no usable data. Seven RCTs evaluated systemic drug treatments (three aprotinin, two desmopressin, two tranexamic acid) and 15 RCTs evaluated topical drug treatments (drug-containing bioabsorbable dressings or glues), including fibrin, thrombin, collagen, gelatin, synthetic sealants and one investigational new agent. Most trials were conducted in high-income countries and the majority of the trials only included participants undergoing elective surgery. We also identified two ongoing RCTs. We were unable to perform the planned network meta-analysis due to the sparse reporting of outcomes relevant to this review. Systemic drug treatments We identified seven trials of three systemic drugs: aprotinin, desmopressin and tranexamic acid, all with placebo controls. The trials of aprotinin and desmopressin were small with very low-certainty evidence for all of our outcomes. Tranexamic acid versus placebo was the systemic drug comparison with the largest number of participants (2 trials; 1460 participants), both at low risk of bias. The largest of these included a total of 9535 individuals undergoing a number of different higher risk surgeries and reported limited information on the vascular subgroup (1399 participants). Neither trial reported the number of units of red cells transfused per participant up to 30 days. Three outcomes were associated with very low-certainty evidence due to the very wide confidence intervals (CIs) resulting from small study sizes and low number of events. These were: all-cause mortality up to 30 days; number of participants requiring an allogeneic blood transfusion up to 30 days; and risk of requiring a repeat procedure or operation due to bleeding. Tranexamic acid may have no effect on the risk of thromboembolic events up to 30 days (risk ratio (RR) 1.10, 95% CI 0.88 to 1.36; 1 trial, 1360 participants; low-certainty evidence due to imprecision). There is one large ongoing trial (8320 participants) comparing tranexamic acid versus placebo in people undergoing non-cardiac surgery who are at high risk of requiring a red cell transfusion. This aims to complete recruitment in April 2023. This trial has primary outcomes of proportion of participants transfused with red blood cells and incidence of venous thromboembolism (DVT or PE). Topical drug treatments Most trials of topical drug treatments were at high risk of bias due to their open-label design (compared with usual care, or liquids were compared with sponges). All of the trials were small, most were very small, and few reported clinically relevant outcomes in the postoperative period. Fibrin sealant versus usual care was the topical drug comparison with the largest number of participants (5 trials, 784 participants). The five trials that compared fibrin sealant with usual care were all at high risk of bias, due to the open-label trial design with no measures put in place to minimise reporting bias. All of the trials were funded by pharmaceutical companies. None of the five trials reported the number of red cells transfused per participant up to 30 days or the number of participants requiring an allogeneic blood transfusion up to 30 days. The other three outcomes were associated with very low-certainty evidence with wide confidence intervals due to small sample sizes and the low number of events, these were: all-cause mortality up to 30 days; risk of requiring a repeat procedure due to bleeding; and risk of thromboembolic disease up to 30 days. We identified one large trial (500 participants) comparing fibrin sealant versus usual care in participants undergoing abdominal aortic aneurysm repair, which has not yet started recruitment. This trial lists death due to arterial disease and reintervention rates as primary outcomes. AUTHORS' CONCLUSIONS Because of a lack of data, we are uncertain whether any systemic or topical treatments used to reduce bleeding due to major vascular surgery have an effect on: all-cause mortality up to 30 days; risk of requiring a repeat procedure or operation due to bleeding; number of red cells transfused per participant up to 30 days or the number of participants requiring an allogeneic blood transfusion up to 30 days. There may be no effect of tranexamic acid on the risk of thromboembolic events up to 30 days, this is important as there has been concern that this risk may be increased. Trials with sample size targets of thousands of participants and clinically relevant outcomes are needed, and we look forward to seeing the results of the ongoing trials in the future.
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Affiliation(s)
- Anair Beverly
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Giok Ong
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Catherine Kimber
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Josie Sandercock
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Wicks
- Cardiac Anaesthesia and Intensive Care, University Hospital Southampton, Southampton, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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Grant O, Mulligan K, Donnelly J, Ní Áinle F, Mhuircheartaigh RN. Management of Hemorrhage During Cesarean Delivery in a Patient With Vascular Ehlers-Danlos Syndrome: A Case Report. A A Pract 2023; 17:e01655. [PMID: 36706158 DOI: 10.1213/xaa.0000000000001655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Parturients with vascular Ehlers-Danlos syndrome are at particular risk of hemorrhage, and there is little evidence to guide prevention or management of hemorrhage in these patients. We present the case of a patient with vascular Ehlers-Danlos syndrome who had a cesarean delivery complicated by an intraoperative hemorrhage. Administration of desmopressin and tranexamic acid appeared to be of marked benefit in achieving hemostasis. To the best of our knowledge, this is the first report of the use of desmopressin during major obstetric hemorrhage in vascular Ehlers-Danlos syndrome.
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Affiliation(s)
| | - Karen Mulligan
- Gynaecology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jennifer Donnelly
- Gynaecology, Mater Misericordiae University Hospital, Dublin, Ireland
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
- University College Dublin School of Medicine, Dublin, Ireland
| | - Fionnuala Ní Áinle
- University College Dublin School of Medicine, Dublin, Ireland
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
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8
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Westfall KM, Ramcharan RN, Anderson HL. Myocardial infarction after craniotomy for asymptomatic meningioma. BMJ Case Rep 2022; 15:e252256. [PMID: 36581354 PMCID: PMC9806024 DOI: 10.1136/bcr-2022-252256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A man in his 40s with a history of coronary artery disease previously treated with a drug-eluting stent presented for elective craniotomy and resection of an asymptomatic but enlarging meningioma. During his craniotomy, he received desmopressin and tranexamic acid for surgical bleeding. Postoperatively, the patient developed chest pain and was found to have an ST-elevation myocardial infarction (MI). Because of the patient's recent neurosurgery, standard post-MI care was contraindicated and he was instead managed symptomatically in the intensive care unit. Echocardiogram on postoperative day 1 demonstrated no regional wall motion abnormalities and an ejection fraction of 60%. His presentation was consistent with thrombosis of his diagonal stent. He was transferred out of the intensive care unit on postoperative day 1 and discharged home on postoperative day 3.
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9
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Ghariani I, Braham N, Veyradier A, Bekir L. Acquired von Willebrand syndrome: Five cases report and literature review. Thromb Res 2022; 218:145-150. [PMID: 36049419 DOI: 10.1016/j.thromres.2022.08.025] [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: 05/12/2022] [Revised: 07/22/2022] [Accepted: 08/23/2022] [Indexed: 10/15/2022]
Abstract
Acquired von Willebrand syndrome is a rare bleeding disorder with laboratory findings similar to those of inherited von Willebrand disease. Principal factors distinguishing acquired von Willebrand syndrome from the latter condition include lack of prior bleeding disorders, diagnosis at older age, negative family history and association with underlying conditions. METHODS Retrospective, monocentric descriptive case series of acquired von Willebrand syndrome diagnosed between 2010 and 2020. Diagnostic criteria included a recent history of bleeding, a negative family history and a presence of underlying disorders. RESULTS Five men were diagnosed with acquired von Willebrand syndrome. All of them presented with recent mucocutaneous bleeding. The biological phenotype was a type 2 von Willebrand disease in all cases, with decreased VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag ratios (<0.7). Lymphoproliferative, autoimmune and cardiovascular diseases were the main underlying conditions identified. Screening for an anti-von Willebrand factor inhibitor was positive in two patients. Four patients received treatment for the underlying disorder. High-dose intravenous immunoglobulins were the most frequent treatment administrated. Improvement of plasma von Willebrand factor levels was observed in four cases. CONCLUSION Acquired von Willebrand syndrome is a rare but potentially serious disease. The diagnostic should be suspected in adults with unusual mucocutaneous bleeding associated with lymphoproliferative, myeloproliferative, autoimmune and cardiovascular disorders.
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Affiliation(s)
- Ines Ghariani
- Department of Laboratory Hematology, University Hospital of Mongi Slim, La Marsa, Tunisia; University of Pharmacy, Monastir, Tunisia.
| | - Néjia Braham
- University of Pharmacy, Monastir, Tunisia; Department of Laboratory Hematology, University Hospital of Farhat Hached, Tunis, Tunisia
| | - Agnès Veyradier
- Department of Laboratory Hematology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Leila Bekir
- Department of Laboratory Hematology, University Hospital of Mongi Slim, La Marsa, Tunisia; University of Pharmacy, Monastir, Tunisia
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10
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Sreeraman S, McKinlay S, Li A, Crowther M, Motalo O. Efficacy of parenteral formulations of desmopressin in the treatment of bleeding disorders: A systematic review. Thromb Res 2022; 213:16-26. [DOI: 10.1016/j.thromres.2022.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/07/2022] [Accepted: 02/21/2022] [Indexed: 01/10/2023]
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11
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Wang S, Hu Q, Chen Y, Hu X, Tang N, Zhang A, Liu A. Case report: A case of acquired von Willebrand syndrome as onset clinical presentation of systemic lupus erythematosus manifested as epistaxis and pulmonary hemorrhage. Front Pediatr 2022; 10:1013764. [PMID: 36204663 PMCID: PMC9530141 DOI: 10.3389/fped.2022.1013764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/02/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Acquired von Willebrand syndrome (AVWS) is a less common bleeding disorder, primarily manifested as mild to moderate mucocutaneous bleeding and laboratory tests are similar to hereditary von Willebrand disease (VWD). AVWS is secondary to other diseases, and systemic lupus erythematosus (SLE) is a relatively rare cause. CASE PRESENTATION We report a case of AVWS as onset clinical presentation of SLE manifested as epistaxis and pulmonary hemorrhage. A 13-year-old male child presented to the hospital with a six-month history of recurrent epistaxis and a one-month history of anemia. Routine blood tests demonstrated severe normocytic anemia and normal platelet count. Von Willebrand test revealed a significantly lower level. High-resolution chest computed tomography (CT) showed patchy ground glass opacities consistent with hemorrhagic changes. After ruling out the family history, the patient was diagnosed with AVWS. Additional tests confirmed positive antinuclear and anti-Sm antibodies. The underlying SLE was diagnosed and treated with methylprednisolone with disease recovery. CONCLUSION We recommend screening for bleeding disorders in patients with recurrent epistaxis. AVWS should be considered when laboratory findings suggest hereditary von Willebrand disease without a personal or familial history of bleeding. In addition, the underlying disease should be explored.
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Affiliation(s)
- Songmi Wang
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qun Hu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yaxian Chen
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiufen Hu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Tang
- Department of Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ai Zhang
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Aiguo Liu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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12
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Barrios RHS, Burguera Vion V, Álvarez Nadal M, Cintra Cabrera M, Elías Triviño S, Villa Hurtado D, Ortego S, Fernández Lucas M, Rivera-Gorrin M. Safety of renal biopsy bleeding prophylaxis with desmopressin. J Int Med Res 2021; 49:3000605211040764. [PMID: 34590925 PMCID: PMC8489756 DOI: 10.1177/03000605211040764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Percutaneous renal biopsy (PRB) is invasive, and bleeding-related complications are a concern. Desmopressin (DDAVP) is a selective type 2 vasopressin receptor-agonist also used for haemostasis. AIM To evaluate the side effects of intravenous (IV) weight-adjusted desmopressin preceding PRB. METHODS This was a retrospective study of renal biopsies performed by nephrologists from 2013 to 2017 in patients who received single-dose DDAVP pre-PRB. RESULTS Of 482 PRBs, 65 (13.5%) received DDAVP (0.3 µg/kg); 55.4% of the PRBs were native kidneys. Desmopressin indications were altered platelet function analyser (PFA)-100 results (75.3% of the patients), urea >24.9 mmol/L (15.5%), antiplatelet drugs (6.1%) and thrombocytopaenia (3%). Of the 65 patients, 30.7% had minor asymptomatic complications, and 3 patients had major complications. Pre-PRB haemoglobin (Hb) <100 g/L was a risk factor for Hb decrease >10 g/L, and altered collagen-epinephrine (Col-Epi) time was a significant risk factor for overall complications. Mean sodium decrease was 0.6 ± 3 mmol/L. Hyponatraemia without neurological symptoms was diagnosed in two patients; no cardiovascular events occurred. CONCLUSION Hyponatraemia after single-dose DDAVP is rare. A single IV dose of desmopressin adjusted to the patient's weight is safe as pre-PRB bleeding prophylaxis.
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Affiliation(s)
- R Haridian Sosa Barrios
- Nephrology Department, Hospital Universitario Ramón y Cajal, IRYCIS Madrid, Spain.,Spanish Group of Diagnostic and Interventional Nephrology, Spanish Society of Nephrology (GNDI), Spain
| | - Víctor Burguera Vion
- Nephrology Department, Hospital Universitario Ramón y Cajal, IRYCIS Madrid, Spain.,Spanish Group of Diagnostic and Interventional Nephrology, Spanish Society of Nephrology (GNDI), Spain
| | - Marta Álvarez Nadal
- Nephrology Department, Hospital Universitario Ramón y Cajal, IRYCIS Madrid, Spain
| | - Melissa Cintra Cabrera
- Spanish Group of Diagnostic and Interventional Nephrology, Spanish Society of Nephrology (GNDI), Spain.,Nephrology Department, Hospital Universitario Virgen de la Macarena, Sevilla, Spain
| | - Sandra Elías Triviño
- Nephrology Department, Hospital Universitario Ramón y Cajal, IRYCIS Madrid, Spain
| | - Daniel Villa Hurtado
- Nephrology Department, Hospital Universitario Ramón y Cajal, IRYCIS Madrid, Spain
| | - Sofía Ortego
- Nephrology Department, Hospital Universitario Ramón y Cajal, IRYCIS Madrid, Spain
| | - Milagros Fernández Lucas
- Nephrology Department, Hospital Universitario Ramón y Cajal, IRYCIS Madrid, Spain.,Spanish Group of Diagnostic and Interventional Nephrology, Spanish Society of Nephrology (GNDI), Spain.,Associate Professor, Alcala University, Madrid, Spain.,Red de investigación renal (REDinREN), ISCIII (ERC 10 RD12/0021/0020) Nephrology, Spain
| | - Maite Rivera-Gorrin
- Nephrology Department, Hospital Universitario Ramón y Cajal, IRYCIS Madrid, Spain.,Spanish Group of Diagnostic and Interventional Nephrology, Spanish Society of Nephrology (GNDI), Spain.,Associate Professor, Alcala University, Madrid, Spain.,Red de investigación renal (REDinREN), ISCIII (ERC 10 RD12/0021/0020) Nephrology, Spain
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13
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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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14
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Riojas CM, Ekaney ML, Ross SW, Cunningham KW, Furay EJ, Brown CVR, Evans SL. Platelet Dysfunction after Traumatic Brain Injury: A Review. J Neurotrauma 2021; 38:819-829. [PMID: 33143502 DOI: 10.1089/neu.2020.7301] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Coagulopathy is a known sequela of traumatic brain injury (TBI) and can lead to increased morbidity and mortality. Platelet dysfunction has been identified as one of several etiologies of coagulopathy following TBI and has been associated with poor outcomes. Regardless of whether the platelet dysfunction occurs as a direct consequence of the injury or because of pre-existing medical comorbidities or medication use, accurate detection and monitoring of response to therapy is key to optimal patient care. Platelet transfusion has been proposed as a potential therapeutic intervention to treat platelet dysfunction, with several studies using platelet function assays to monitor response. The development of increasingly precise diagnostic testing is providing enhanced understanding of the specific derangement in the hemostatic process, allowing clinicians to provide patient-specific treatment plans. There is wide variability in the currently available literature on the incidence and clinical significance of platelet dysfunction following TBI, which creates challenges with developing evidence-based management guidelines. The relatively high prevalence of platelet inhibitor therapy serves as an additional confounding factor. In addition, the data are largely retrospective in nature. We performed a literature review to provide clarity on this clinical issue. We reviewed 348 abstracts, and included 97 manuscripts in our final literature review. Based on the currently available research, platelet dysfunction has been consistently demonstrated in patients with moderate-severe TBI. We recommend the use of platelet functional assays to evaluate patients with TBI. Platelet transfusion directed at platelet dysfunction may lead to improved clinical outcome. A randomized trial guided by implementation science could improve the applicability of these practices.
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Affiliation(s)
- Christina M Riojas
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Michael L Ekaney
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Samuel W Ross
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Kyle W Cunningham
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Elisa J Furay
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Carlos V R Brown
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Susan L Evans
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
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15
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Affiliation(s)
- Nathan Goad
- Nathan Goad is Critical Care Clinical Pharmacist, Medical Intensive Care Unit, Department of Pharmacy Services, Cabell Huntington Hospital, Huntington, WV 25701
| | - Melissa Levesque
- Melissa Levesque is Critical Care Clinical Pharmacist, Neurosciences, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida
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16
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Andersen LK, Hvas AM, Hvas CL. Effect of Desmopressin on Platelet Dysfunction During Antiplatelet Therapy: A Systematic Review. Neurocrit Care 2020; 34:1026-1046. [PMID: 32748210 DOI: 10.1007/s12028-020-01055-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE An increasing number of patients receive antiplatelet therapy. Patients exposed to surgery while receiving platelet inhibitors hold an increased bleeding risk. Especially in neurosurgery and neurocritical care patients, bleeding and hematoma expansion are feared complications as even minor bleedings may be hazardous. The objective of this systematic review was to investigate the effect of desmopressin (1-deamino-8-D-arginine vasopressin, DDAVP) on platelet function during antiplatelet therapy in patients undergoing non-cardiac surgery, patients who experience spontaneous or traumatic hemorrhage, healthy individuals and in animals. METHODS Studies were identified through a systematic literature search in PubMed and EMBASE on August 19, 2019, with an update on May 2, 2020, and from reference lists of the included studies. Data on clinical and biochemical effect of DDAVP were extracted from included studies for a qualitative data synthesis. RESULTS In total, 22 studies were included: 18 human studies and four animal studies. Overall, DDAVP improved bleeding time and increased platelet aggregation in patients undergoing non-cardiac surgery, patients suffering intracerebral or subarachnoid hemorrhage while receiving antiplatelet therapy as well as in healthy individuals and animals exposed to antiplatelet therapy. Observational data indicate that DDAVP may mitigate hematoma expansion in patients with intracerebral hemorrhage or traumatic brain injury. CONCLUSIONS The present data hold biochemical evidence that DDAVP improves platelet function during antiplatelet therapy in humans and animals. The need for randomized trials is evident in order to evaluate the potential clinical effect of DDAVP in management of patients with spontaneous or traumatic hemorrhage, or undergoing neurosurgery, while receiving antiplatelet therapy.
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Affiliation(s)
- Lise Kjær Andersen
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.
| | - Christine Lodberg Hvas
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
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17
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Beverly A, Ong G, Doree C, Welton NJ, Estcourt LJ. Drugs to reduce bleeding and transfusion in major open vascular or endovascular surgery: a systematic review and network meta-analysis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Anair Beverly
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Giok Ong
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Carolyn Doree
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School; University of Bristol; Bristol UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine; NHS Blood and Transplant; Oxford UK
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18
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Franchini M, Mannucci PM. Acquired von Willebrand syndrome: focused for hematologists. Haematologica 2020; 105:2032-2037. [PMID: 32554559 PMCID: PMC7395262 DOI: 10.3324/haematol.2020.255117] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/27/2020] [Indexed: 12/16/2022] Open
Abstract
The acquired von Willebrand syndrome (AvWS) is a rare bleeding disorder with laboratory findings similar to those of inherited von Willebrand disease. However, unlike the inherited disease, AvWS occurs in persons with no personal and family history of bleeding and is often associated with a variety of underlying diseases, most frequently lymphoproliferative, myeloproliferative and cardiovascular disorders. After the presentation of a typical case, in this narrative review we discuss the more recent data on the pathophysiology, clinical, laboratory and therapeutic aspects of this acquired bleeding syndrome. We chose to focus particularly on those aspects of greater interest for the hematologist.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantua
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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19
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Athavale A, Kulkarni H, Arslan CD, Hart P. Desmopressin and bleeding risk after percutaneous kidney biopsy. BMC Nephrol 2019; 20:413. [PMID: 31730448 PMCID: PMC6858772 DOI: 10.1186/s12882-019-1595-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/16/2019] [Indexed: 01/17/2023] Open
Abstract
Background Desmopressin is used to reduce bleeding after kidney biopsy but evidence supporting its use is weak, especially in patients with elevated creatinine. The present study was undertaken to evaluate efficacy of desmopressin in reducing bleeding after percutaneous kidney biopsy. Methods Retrospective cohort study. 269 of 322 patients undergoing percutaneous kidney biopsy between January 1, 2014 and January 31, 2018 were included. Patients had normal bleeding time, platelet count and coagulation profile. Primary outcome was defined as composite of hemoglobin drop ≥1 g/dL, hematoma on post biopsy ultrasound, gross hematuria, erythrocyte transfusion or angiography to stop bleeding. Association of desmopressin with outcomes was assessed using linear (for continuous variables) and logistic (for binary variables) regression models. Propensity score was used to minimize potential confounding. Results Desmopressin was administered to 100/269 (37.17%) patients. After propensity score adjustment patients who received desmopressin had increased odds of post biopsy bleeding [OR 3.88 (1.95–7.74), p < 0.001]. Creatinine at time of biopsy influenced bleeding risk; gender, emergent vs elective biopsy, obesity, AKI, diabetes, hypertension or bleeding time did not influence bleeding risk. Administration of desmopressin to patients with serum creatinine ≥1.8 mg/dL decreased bleeding risk [OR 2.11 (95% CI 0.87–5.11), p = 0.09] but increased bleeding risk when serum creatinine was < 1.8 mg/dL (OR 9.72 (95% CI 2.95–31.96), p < 0.001). Conclusion Desmopressin should not be used routinely prior to percutaneous kidney biopsy in patients at low risk for bleeding but should be reserved for patients who are at high risk for bleeding.
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Affiliation(s)
- Ambarish Athavale
- Division of Nephrology, Cook County Health, 1950 W. Polk Street, 5th Floor, Chicago, IL, 60605, USA.
| | | | - Cagil D Arslan
- Division of Nephrology, Cook County Health, 1950 W. Polk Street, 5th Floor, Chicago, IL, 60605, USA
| | - Peter Hart
- Division of Nephrology, Cook County Health, 1950 W. Polk Street, 5th Floor, Chicago, IL, 60605, USA
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20
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Desmopressin is a transfusion sparing option to reverse platelet dysfunction in patients with severe traumatic brain injury. J Trauma Acute Care Surg 2019; 88:80-86. [DOI: 10.1097/ta.0000000000002521] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Beverly A, Ong G, Wilkinson KL, Doree C, Welton NJ, Estcourt LJ. Drugs to reduce bleeding and transfusion in adults undergoing cardiac surgery: a systematic review and network meta-analysis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Anair Beverly
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Giok Ong
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Kirstin L Wilkinson
- Southampton University NHS Hospital; Paediatric and Adult Cardiothoracic Anaesthesia; Tremona Road Southampton UK SO16 6YD
| | - Carolyn Doree
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Nicky J Welton
- University of Bristol; Population Health Sciences, Bristol Medical School; Bristol UK
| | - Lise J Estcourt
- NHS Blood and Transplant; Haematology/Transfusion Medicine; Level 2, John Radcliffe Hospital Headington Oxford UK OX3 9BQ
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22
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Machovec KA, Jooste EH. Pediatric Transfusion Algorithms: Coming to a Cardiac Operating Room Near You. J Cardiothorac Vasc Anesth 2019; 33:2017-2029. [DOI: 10.1053/j.jvca.2018.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Indexed: 01/27/2023]
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23
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Bakdash K, Schramm KM, Annam A, Brown M, Kondo K, Lindquist JD. Complications of Percutaneous Renal Biopsy. Semin Intervent Radiol 2019; 36:97-103. [PMID: 31123379 DOI: 10.1055/s-0039-1688422] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Percutaneous renal biopsy is widely used for diagnosis, prognosis, and management of nephropathies. Complications may arise after renal biopsy, most commonly in the form of bleeding. Efforts should be taken to optimize modifiable risk factors such as hypertension, thrombocytopenia, and coagulopathy prior to the procedure. Unmodifiable risk factors such as poor renal function, gender, and underlying histologic diagnosis may be used to identify high-risk patients. Delayed presentation of bleeding complications is common, and close clinical follow-up is crucial.
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Affiliation(s)
- Kenaz Bakdash
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Kristofer M Schramm
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Aparna Annam
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Matthew Brown
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Kimi Kondo
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Jonathan D Lindquist
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado, Anschutz Medical Center, Aurora, Colorado
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24
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Hofer V, Wrigge H, Wienke A, Hofmann G, Hilbert-Carius P. [Platelet function disorder in trauma patients, an underestimated problem? Results of a single center study]. Anaesthesist 2019; 68:368-376. [PMID: 31098664 DOI: 10.1007/s00101-019-0597-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/27/2019] [Accepted: 04/03/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Plasmatic coagulation disorders in trauma patients are common and their management is subject to current guidelines. Less evidence exists for platelet function. Although it is known that several trauma-associated factors have a negative influence on platelet function, routine monitoring has not yet become established. METHODS A retrospective single center study was carried out at a German level 1 trauma center from 2010 to 2016. In all patients fulfilling the requirements for the German Trauma Society (DGU) Traumaregister® who were admitted directly from the scene of the incident, platelet function was analyzed using the Platelet Function Analyzer (PFA 100®) with adenosine diphosphate (ADP) and epinephrine as activation factors. After exclusion of patients with intake of long-term anticoagulant and antiaggregant medication, possible influencing factors of a reduced platelet function were identified. RESULTS The results from 310 patients (44.0 ± 14.7 years, 76% male, Injury Severity Score, ISS 28.4 ± 14.2 points) were available. A delayed platelet activation was found in 25.5% using ADP and 31% using epinephrine. Laboratory parameters indicated a greater blood loss. Prolonged closure times were associated with an increased transfusion rate of packed red blood cell concentrates and a higher mortality rate. Logistic regression revealed hemoglobin (Hb) and fibrinogen levels at admission to be independent predictors for a decreased platelet activation in the assay with ADP (p < 0.001, Cohen's f = 0.61) and with epinephrine (p < 0.001, f = 0.42). CONCLUSION Approximately one quarter to one third of primarily admitted trauma patients without long-term anticoagulation medication showed a delayed platelet activation in the PFA-100 test. By considering all trauma patients an even higher rate can be expected. The Hb and fibrinogen levels at admission can be helpful to estimate platelet disorders. The development of platelet assays to guide the resuscitation of individual patients seems to be absolutely necessary. The contribution of platelet disorders to trauma-induced coagulopathy is not sufficiently understood. Regarding the importance assigned to platelet transfusion or administration of desmopressin, these aspects should be the subject of further research.
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Affiliation(s)
- V Hofer
- Klinik für Anästhesiologie, Intensiv‑, Notfallmedizin und Schmerztherapie, Bergmannstrost BG-Klinikum Halle (Saale), Merseburgerstr. 165, 06112, Halle (Saale), Deutschland.,Klinik für Anästhesiologie, Universitätsklinik Regensburg, Regensburg, Deutschland
| | - H Wrigge
- Klinik für Anästhesiologie, Intensiv‑, Notfallmedizin und Schmerztherapie, Bergmannstrost BG-Klinikum Halle (Saale), Merseburgerstr. 165, 06112, Halle (Saale), Deutschland
| | - A Wienke
- Institut für Medizinische Epidemiologie, Biometrie und Informatik, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - G Hofmann
- Klinik für Unfall- und Wiederherstellungschirurgie, Bergmannstrost BG-Klinikum Halle (Saale), Halle (Saale), Deutschland.,Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie Universitätsklinikum, Friedrich Schiller Universität Jena, Jena, Deutschland
| | - P Hilbert-Carius
- Klinik für Anästhesiologie, Intensiv‑, Notfallmedizin und Schmerztherapie, Bergmannstrost BG-Klinikum Halle (Saale), Merseburgerstr. 165, 06112, Halle (Saale), Deutschland.
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25
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Strategies for Individualized Dosing of Clotting Factor Concentrates and Desmopressin in Hemophilia A and B. Ther Drug Monit 2019; 41:192-212. [DOI: 10.1097/ftd.0000000000000625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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26
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Impact of drugs on venous thromboembolism risk in surgical patients. Eur J Clin Pharmacol 2019; 75:751-767. [DOI: 10.1007/s00228-019-02636-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/21/2019] [Indexed: 01/14/2023]
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27
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Francoeur CL, Roh D, Schmidt JM, Mayer SA, Falo MC, Agarwal S, Connolly ES, Claassen J, Elkind MS, Park S. Desmopressin administration and rebleeding in subarachnoid hemorrhage: analysis of an observational prospective database. J Neurosurg 2019; 130:502-508. [PMID: 29393750 PMCID: PMC6688966 DOI: 10.3171/2017.7.jns17990] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/14/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Rebleeding remains a frequent and catastrophic event leading to poor outcome after subarachnoid hemorrhage (SAH). Reduced platelet function after the initial bleed is associated with higher risk of early rebleeding. Desmopressin (DDAVP) is a well-known hemostatic agent, and recent guidelines already suggest its use in individuals exposed to antiplatelet drugs. The authors hypothesized that DDAVP administration in patients with SAH at admission would be associated with lower risks of rebleeding. METHODS The authors performed an observational cohort study of patients enrolled in the Columbia University SAH Outcome Project between August 1996 and July 2015. The authors compared the rate of rebleeding between patients who were and those who were not treated with DDAVP. After adjustment for known predictors, logistic regression was used to measure the association between treatment with DDAVP and risks of rebleeding. RESULTS Among 1639 patients with SAH, 12% were treated with DDAVP. The main indication for treatment was suspected exposure to an antiplatelet agent. The overall incidence of rebleeding was 9% (1% among patients treated with DDAVP compared with 8% among those not treated). After adjustment for antiplatelet use and known predictors, treatment with DDAVP was associated with a 45% reduction in the risks of rebleeding (adjusted OR 0.55, 95% CI 0.27-0.97). DDAVP was associated with a higher incidence of hyponatremia but not with thrombotic events or delayed cerebral ischemia. CONCLUSIONS Treatment with DDAVP was associated with a lower risk of rebleeding among patients with SAH. These findings support further study of DDAVP as first-line therapy for medical hemostasis in patients with SAH.
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Affiliation(s)
- Charles L. Francoeur
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Université Laval, Québec, Québec, Canada; Department of Critical Care, CHU de Québec—Université Laval, 1401 18e rue Québec, Québec G1J 1Z4, Canada
| | - David Roh
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - J. Michael Schmidt
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Stephan A. Mayer
- Department of Neurology, Neuroscience Institute, Henry Ford Health System, 2799 W. Grand Blvd, Detroit MI 48202
| | - M. Cristina Falo
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Sachin Agarwal
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - E. Sander Connolly
- Department of Neurosurgery, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States, United States
| | - Jan Claassen
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Mitchell S Elkind
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
| | - Soojin Park
- Department of Neurology, College of Physicians and Surgeons, Neurological Institute, Columbia University, 710 West 168th Street New York, NY 10032-3784, United States
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Franchini M, Marano G, Pupella S, Vaglio S, Veropalumbo E, Liumbruno GM. Management of mild hemophilia A. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1529563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Massimo Franchini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy
| | - Giuseppe Marano
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Simonetta Pupella
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Eva Veropalumbo
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Hews-Girard J, Rydz N, Lee A, Goodyear MD, Poon MC. Desmopressin in non-severe haemophilia A: Test-response and clinical outcomes in a single Canadian centre review. Haemophilia 2018; 24:720-725. [PMID: 30004154 DOI: 10.1111/hae.13586] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Desmopressin is an effective haemostatic agent for patients with non-severe haemophilia A; however, response may differ between patients of similar severity. Responsiveness is classified based on various cut-off values for plasma levels of FVIII post-desmopressin administration. Patients may be classified differently depending on the values chosen. AIM To classify desmopressin response in non-severe haemophilia A patients with respect to current test-response definitions. Also, to characterize relationships between test response and clinical outcome of desmopressin use. METHODS Current desmopressin test-response definitions were obtained from the literature. We adopted peak FVIII level (at 1 hour post-administration) ≥50 IU/dL and <20 IU/dL as complete and no response, respectively, thereby satisfying most reported definitions. Test-responses and clinical outcomes of use between 2007 and 2017 for adult mild/moderate haemophilia A patients were reviewed and correlated. RESULTS All patients classified as complete responders (n = 31; peak FVIII ≥50 IU/dL) and the majority of partial responders (n = 11; peak FVIII ≥20 to <50 IU/dL) had good clinical outcomes after desmopressin use for a variety of bleeding episodes and procedures. Two non-responders (peak FVIII <20 IU/dL) given desmopressin for minor bleeding/procedures also had good clinical outcomes. One patient with a partial test-response (peak FVIII 23 IU/dL) required additional factor concentrate to achieve haemostasis. CONCLUSIONS Based on our review, we suggest that the determination of desmopressin responsiveness should consider both the change in plasma FVIII levels as well as clinical outcomes associated with prior therapeutic use.
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Affiliation(s)
- Julia Hews-Girard
- Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Natalia Rydz
- Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada.,University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Adrienne Lee
- Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada.,University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Marilyn Dawn Goodyear
- Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada.,University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Man-Chiu Poon
- Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada.,University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Abou-Ismail MY, Ogunbayo GO, Secic M, Kouides PA. Outgrowing the laboratory diagnosis of type 1 von Willebrand disease: A two decade study. Am J Hematol 2018; 93:232-237. [PMID: 29098718 DOI: 10.1002/ajh.24962] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 10/24/2017] [Accepted: 10/31/2017] [Indexed: 11/06/2022]
Abstract
Von Willebrand Factor (VWF) levels are known to increase with age in the general population, but that effect is unclear in von Willebrand disease (VWD) patients. Thus, it is important to assess the trends of VWF levels with age, and the extent and rate of their normalization in patients with VWD. In a retrospective cohort study, we reviewed the medical records of 126 patients between 1996 and 2016 who met the NHLBI diagnostic criteria for type 1 VWD or "Low VWF" (LVWF). We followed all their historically documented VWF antigen (VWF:Ag), VWF activity (VWF:RCo), and Factor VIII (FVIII) levels longitudinally over time, correlating data with clinical setting at time of testing. The average duration of follow-up was 10.5 ± 3.7 years (SD). Out of the total study population, 27.8% achieved the primary outcome of complete normalization (CN) of both VWF:Ag and VWF:RCo levels, including 19.6% and 32.5% of those with VWD and LVWF, respectively. Linear regression demonstrated statistically significant positive trends of VWF:Ag, VWF:RCo, FVIII with time, calculated at 2.4, 1.4, and 1.4 U dL-1/year, respectively (P < .001 each). In the largest study population of VWD patients to date whose levels were followed longitudinally, there is a statistically significant rise in VWF:Ag, VWF:RCo, and FVIII levels observed with time. CN of both VWF:Ag and VWF:RCo levels was observed in almost a third of patients with VWD or LVWF, over an average of 10 years. Whether the bleeding phenotype also improves is unclear and requires further study.
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Affiliation(s)
| | | | | | - Peter A. Kouides
- Department of Medicine; Rochester General Hospital; Rochester New York
- Mary M. Gooley Hemophila Center; Rochester New York
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Franquiz MJ, Hines MC, Yeung SYA. Comparison of Two Weight-Based Desmopressin Dosing Strategies for Spontaneous Bleeding. Ann Pharmacother 2018; 52:527-532. [PMID: 29332421 DOI: 10.1177/1060028017752354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The pharmacokinetics and pharmacodynamics of desmopressin are appropriate for adjusted body weight-based dosing, particularly in obese patients. OBJECTIVE The objective of this study was to describe desmopressin dosing strategies, with emphasis on hemostatic outcomes among patients without preexisting bleeding disorders. METHODS This was a single-center, retrospective cohort study of patients who received intravenous weight-based desmopressin for a hemostatic indication. Demographics, comorbidities, treatment setting, indication, site of bleeding, and outcomes were collected from the medical record. Primary outcomes included need for procedural intervention to achieve hemostasis, transfusion requirement, and death. Association between desmopressin dose and outcome was evaluated using χ2 or Fischer's exact tests and logistic and linear regression models. Multiple regression analysis was conducted to identify other predictors of outcome in the data set. RESULTS A total of 109 patients were included (n = 26, dose adjustment; n = 83, no dose adjustment). Baseline characteristics were well-matched between groups: mean (SD) age of 57.0 (13.5) years; mean (SD) Charlson Comorbidity Score of 6.5 (2.8); 37% were obese; 76% were critically ill; 81% were actively bleeding without differences in site of bleeding; and crude mortality was 39%. No differences in death, mean units of packed red blood cells transfused, or need for procedural hemostasis were observed between adjusted weight- and actual weight-based desmopressin dosing. CONCLUSIONS When used adjunctively to blood product transfusion in actively bleeding patients, use of adjusted body weight-based desmopressin did not negatively affect clinical outcomes. More data are needed to confirm this dosing strategy.
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Hickman DA, Pawlowski CL, Sekhon UDS, Marks J, Gupta AS. Biomaterials and Advanced Technologies for Hemostatic Management of Bleeding. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2018; 30:10.1002/adma.201700859. [PMID: 29164804 PMCID: PMC5831165 DOI: 10.1002/adma.201700859] [Citation(s) in RCA: 260] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 06/18/2017] [Indexed: 05/03/2023]
Abstract
Bleeding complications arising from trauma, surgery, and as congenital, disease-associated, or drug-induced blood disorders can cause significant morbidities and mortalities in civilian and military populations. Therefore, stoppage of bleeding (hemostasis) is of paramount clinical significance in prophylactic, surgical, and emergency scenarios. For externally accessible injuries, a variety of natural and synthetic biomaterials have undergone robust research, leading to hemostatic technologies including glues, bandages, tamponades, tourniquets, dressings, and procoagulant powders. In contrast, treatment of internal noncompressible hemorrhage still heavily depends on transfusion of whole blood or blood's hemostatic components (platelets, fibrinogen, and coagulation factors). Transfusion of platelets poses significant challenges of limited availability, high cost, contamination risks, short shelf-life, low portability, performance variability, and immunological side effects, while use of fibrinogen or coagulation factors provides only partial mechanisms for hemostasis. With such considerations, significant interdisciplinary research endeavors have been focused on developing materials and technologies that can be manufactured conveniently, sterilized to minimize contamination and enhance shelf-life, and administered intravenously to mimic, leverage, and amplify physiological hemostatic mechanisms. Here, a comprehensive review regarding the various topical, intracavitary, and intravenous hemostatic technologies in terms of materials, mechanisms, and state-of-art is provided, and challenges and opportunities to help advancement of the field are discussed.
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Affiliation(s)
- DaShawn A Hickman
- Case Western Reserve University School of Medicine, Department of Pathology, Cleveland, Ohio 44106, USA
| | - Christa L Pawlowski
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Ujjal D S Sekhon
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Joyann Marks
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Anirban Sen Gupta
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
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Desborough MJ, Oakland K, Brierley C, Bennett S, Doree C, Trivella M, Hopewell S, Stanworth SJ, Estcourt LJ. Desmopressin use for minimising perioperative blood transfusion. Cochrane Database Syst Rev 2017; 7:CD001884. [PMID: 28691229 PMCID: PMC5546394 DOI: 10.1002/14651858.cd001884.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Blood transfusion is administered during many types of surgery, but its efficacy and safety are increasingly questioned. Evaluation of the efficacy of agents, such as desmopressin (DDAVP; 1-deamino-8-D-arginine-vasopressin), that may reduce perioperative blood loss is needed. OBJECTIVES To examine the evidence for the efficacy of DDAVP in reducing perioperative blood loss and the need for red cell transfusion in people who do not have inherited bleeding disorders. SEARCH METHODS We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (2017, issue 3) in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (from 1937), the Transfusion Evidence Library (from 1980), and ongoing trial databases (all searches to 3 April 2017). SELECTION CRITERIA We included randomised controlled trials comparing DDAVP to placebo or an active comparator (e.g. tranexamic acid, aprotinin) before, during, or immediately after surgery or after invasive procedures in adults or children. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 65 completed trials (3874 participants) and four ongoing trials. Of the 65 completed trials, 39 focused on adult cardiac surgery, three on paediatric cardiac surgery, 12 on orthopaedic surgery, two on plastic surgery, and two on vascular surgery; seven studies were conducted in surgery for other conditions. These trials were conducted between 1986 and 2016, and 11 were funded by pharmaceutical companies or by a party with a commercial interest in the outcome of the trial.The GRADE quality of evidence was very low to moderate across all outcomes. No trial reported quality of life. DDAVP versus placebo or no treatmentTrial results showed considerable heterogeneity between surgical settings for total volume of red cells transfused (low-quality evidence) and for total blood loss (very low-quality evidence) due to large differences in baseline blood loss. Consequently, these outcomes were not pooled and were reported in subgroups.Compared with placebo, DDAVP may slightly decrease the total volume of red cells transfused in adult cardiac surgery (mean difference (MD) -0.52 units, 95% confidence interval (CI) -0.96 to -0.08 units; 14 trials, 957 participants), but may lead to little or no difference in orthopaedic surgery (MD -0.02, 95% CI -0.67 to 0.64 units; 6 trials, 303 participants), vascular surgery (MD 0.06, 95% CI -0.60 to 0.73 units; 2 trials, 135 participants), or hepatic surgery (MD -0.47, 95% CI -1.27 to 0.33 units; 1 trial, 59 participants).DDAVP probably leads to little or no difference in the total number of participants transfused with blood (risk ratio (RR) 0.96, 95% CI 0.86 to 1.06; 25 trials; 1806 participants) (moderate-quality evidence).Whether DDAVP decreases total blood loss in adult cardiac surgery (MD -135.24 mL, 95% CI -210.80 mL to -59.68 mL; 22 trials, 1358 participants), orthopaedic surgery (MD -285.76 mL, 95% CI -514.99 mL to -56.53 mL; 5 trials, 241 participants), or vascular surgery (MD -582.00 mL, 95% CI -1264.07 mL to 100.07 mL; 1 trial, 44 participants) is uncertain because the quality of evidence is very low.DDAVP probably leads to little or no difference in all-cause mortality (Peto odds ratio (pOR) 1.09, 95% CI 0.51 to 2.34; 22 trials, 1631 participants) or in thrombotic events (pOR 1.36, 95% CI, 0.85 to 2.16; 29 trials, 1984 participants) (both low-quality evidence). DDAVP versus placebo or no treatment for people with platelet dysfunctionCompared with placebo, DDAVP may lead to a reduction in the total volume of red cells transfused (MD -0.65 units, 95% CI -1.16 to -0.13 units; 6 trials, 388 participants) (low-quality evidence) and in total blood loss (MD -253.93 mL, 95% CI -408.01 mL to -99.85 mL; 7 trials, 422 participants) (low-quality evidence).DDAVP probably leads to little or no difference in the total number of participants receiving a red cell transfusion (RR 0.83, 95% CI 0.66 to 1.04; 5 trials, 258 participants) (moderate-quality evidence).Whether DDAVP leads to a difference in all-cause mortality (pOR 0.72, 95% CI 0.12 to 4.22; 7 trials; 422 participants) or in thrombotic events (pOR 1.58, 95% CI 0.60 to 4.17; 7 trials, 422 participants) is uncertain because the quality of evidence is very low. DDAVP versus tranexamic acidCompared with tranexamic acid, DDAVP may increase the volume of blood transfused (MD 0.6 units, 95% CI 0.09 to 1.11 units; 1 trial, 40 participants) and total blood loss (MD 142.81 mL, 95% CI 79.78 mL to 205.84 mL; 2 trials, 115 participants) (both low-quality evidence).Whether DDAVP increases or decreases the total number of participants transfused with blood is uncertain because the quality of evidence is very low (RR 2.42, 95% CI 1.04 to 5.64; 3 trials, 135 participants).No trial reported all-cause mortality.Whether DDAVP leads to a difference in thrombotic events is uncertain because the quality of evidence is very low (pOR 2.92, 95% CI 0.32 to 26.83; 2 trials, 115 participants). DDAVP versus aprotininCompared with aprotinin, DDAVP probably increases the total number of participants transfused with blood (RR 2.41, 95% CI 1.45 to 4.02; 1 trial, 99 participants) (moderate-quality evidence).No trials reported volume of blood transfused or total blood loss and the single trial that included mortality as an outcome reported no deaths.Whether DDAVP leads to a difference in thrombotic events is uncertain because the quality of evidence is very low (pOR 0.98, 95% CI 0.06 to 15.89; 2 trials, 152 participants). AUTHORS' CONCLUSIONS Most of the evidence derived by comparing DDAVP versus placebo was obtained in cardiac surgery, where DDAVP was administered after cardiopulmonary bypass. In adults undergoing cardiac surgery, the reduction in volume of red cells transfused and total blood loss was small and was unlikely to be clinically important. It is less clear whether DDAVP may be of benefit for children and for those undergoing non-cardiac surgery. A key area for researchers is examining the effects of DDAVP for people with platelet dysfunction. Few trials have compared DDAVP versus tranexamic acid or aprotinin; consequently, we are uncertain of the relative efficacy of these interventions.
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Affiliation(s)
| | - Kathryn Oakland
- NHS Blood and TransplantHaematology/Transfusion MedicineOxfordUK
| | - Charlotte Brierley
- John Radcliffe HospitalDepartment of HaematologyHeadley WayOxfordUKOX3 9DU
| | - Sean Bennett
- University of OttawaDepartment of Surgery501 Smyth RoadOttawaOntarioCanadaK1M 1R4
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Sally Hopewell
- University of OxfordOxford Clinical Trials Research UnitNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesWindmill RoadOxfordOxfordshireUKOX3 7LD
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
| | - Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineOxfordUK
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Abstract
Collagens mediate essential hemostasis by maintaining the integrity and stability of the vascular wall. Imbalanced turnover of collagens by uncontrolled formation and/or degradation may result in pathologic conditions such as fibrosis. Thickening of the vessel wall because of accumulation of collagens may lead to arterial occlusion or thrombosis. Thinning of the wall because of collagen degradation or deficiency may lead to rupture of the vessel wall or aneurysm. Preventing excessive hemorrhage or thrombosis relies on collagen-mediated actions. Von Willebrand factor, integrins and glycoprotein VI, as well as clotting factors, can bind collagen to restore normal hemostasis after trauma. This review outlines the essential roles of collagens in mediating hemostasis, with a focus on collagens types I, III, IV, VI, XV, and XVIII.
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Affiliation(s)
| | - N G Kjeld
- Nordic Bioscience A/S, Herlev, Denmark
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Pearson K, Jensen H, Kander T, Schött U. Desmopressinin vitroeffects on platelet function, monitored with Multiplate, ROTEM and Sonoclot. Scand J Clin Lab Invest 2016; 76:282-90. [DOI: 10.3109/00365513.2016.1149615] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Windyga J, Dolan G, Altisent C, Katsarou O, López Fernández MF, Zülfikar B. Practical aspects of DDAVP use in patients with von Willebrand Disease undergoing invasive procedures: a European survey. Haemophilia 2015. [PMID: 26207933 DOI: 10.1111/hae.12763] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Desamino D-arginine vasopressin (DDAVP or desmopressin) is a useful and effective haemostatic treatment for patients with von Willebrand Disease (VWD). However, there are still issues regarding in which subtypes of VWD DDAVP is appropriate and little consensus on its use in different surgical settings. We also lack information concerning the appropriate laboratory parameters that should be monitored. AIM The European Haemophilia Therapy Strategy Board (EHTSB) wished to investigate published information and clinical use of DDAVP in VWD patients. METHODS We conducted a literature survey on management of VWD during surgical interventions and undertook a survey of specialist haematologist centres across Europe to assess current management of VWD patients. RESULTS DDAVP is ineffective in type 3 VWD and its use in type 2B remains controversial due to the possibility of thrombocytopenia. It can, however, be used effectively to cover minor surgery and dental procedures in most other VWD patients. For major surgery there is wider use of factor concentrate in preference to DDAVP depending on the subtype of VWD. We give consensus recommendations on the use of DDAVP for surgical interventions in VWD including laboratory parameters that denote an adequate response and contraindications to its use. CONCLUSIONS DDAVP can be recommended to cover invasive procedure in selected patients with VWD, however, we need more information and systematic recording of adverse events associated with DDAVP use in VWD. A companion paper will be published covering the use of factor concentrates in VWD patients.
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Affiliation(s)
- J Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - G Dolan
- Queen's Medical Centre, University Hospital, Nottingham, UK
| | - C Altisent
- Servicio de Hematologia - Unidad de Hemofilia, Hospital Vall D'Hebron, Barcelona, Spain
| | - O Katsarou
- Thrombosis and Haemostasis Unit, Laikon General Hospital, Athens, Greece
| | - M-F López Fernández
- Servicio Hematologia, Complexo Hospitalario A Coruña, INIBIC. Avenida del Pasaje., La Coruña, Spain
| | - B Zülfikar
- Department of Pediatric Hematology, Istanbul University Cerrahpasa Faculty of Medicine, Cerrahpasa, Istanbul, Turkey
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Tsui PY, Cheung CW, Lee Y, Leung SWS, Ng KFJ. The effectiveness of low-dose desmopressin in improving hypothermia-induced impairment of primary haemostasis under influence of aspirin - a randomized controlled trial. BMC Anesthesiol 2015; 15:80. [PMID: 26017715 PMCID: PMC4469427 DOI: 10.1186/s12871-015-0061-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 05/21/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Mild hypothermia (34-35 °C) increases perioperative blood loss. Our previous studies showed that desmopressin could have in vitro beneficial effects on hypothermia-induced primary haemostasis impairment. In this study, we investigate the in vitro effects of desmopressin on hypothermia-induced primary haemostasis impairment under the influence of aspirin in healthy volunteers. METHODS Sixty healthy volunteers were randomly allocated to taking aspirin 100 mg or placebo for three days. On the sixth day blood samples were taken before and after the injection of desmopressin (1.5 microgram or 5 microgram) or normal saline subcutaneously. Measurements including Platelet Function Analyzer (PFA-100®) closure times, plasma von Willebrand Factor antigen, haemoglobin and platelet levels were made at 32 °C and 37 °C respectively. RESULTS Collagen/epinephrine closure time (EPICT) was significantly prolonged by 21.13 % (95 %CI 2.34-39.74 %, p = 0.021) in aspirin group at 37 °C. While hypothermia alone prolonged both collagen/adenosine diphosphate (ADPCT) and EPICT by 17.63 % (95 %CI 13.5-20.85 %, p < 0.001) and 8.0 % (95 %CI 6.38-10.04 %, p = 0.024) respectively, addition of aspirin only further prolonged EPICT by 19.9 % (95 %CI 3.32-36.49 %, p = 0.013). In aspirin group, desmopressin 1.5 microgram and 5 microgram significantly reduced ADPCT to below baseline levels at 37 °C (p = 0.025 and <0.001 respectively), whereas reduction in EPICT was seen with desmopressin 5 microgram (p =0.008). The effect was less pronounced at 32 °C, with a significant reduction in EPICT obtained with a dosage of 5 microgram only (p = 0.011). CONCLUSION It was shown that aspirin could further potentiate the hypothermia-induced closure time prolongations. Low dose desmopressin (1.5 microgram) reduced PFA-100® closure times towards baseline. A higher dosage (5 microgram) further reduced the closure times below baseline. Therefore low dose desmopressin (1.5 microgram) might have the potential to correct hypothermia-induced primary haemostasis impairment under the influence of aspirin during the perioperative period. TRIAL REGISTRATION ClinicalTrials.gov: NCT01382134.
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Affiliation(s)
- Pui Yee Tsui
- Department of Anaesthesia, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong, SAR, China.
| | - Chi Wai Cheung
- Department of Anaesthesiology, The University of Hong Kong, Room K424, 4th Floor, K Block, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong, SAR, China.
| | - Yvonne Lee
- Department of Anaesthesiology, The University of Hong Kong, Room K424, 4th Floor, K Block, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong, SAR, China.
| | - Susan Wai Sum Leung
- Department of Pharmacology & Pharmacy, The University of Hong Kong, Hong Kong, SAR, China.
| | - Kwok Fu Jacobus Ng
- Department of Anaesthesiology, The University of Hong Kong, Room K424, 4th Floor, K Block, Queen Mary Hospital, 102 Pokfulam Road, Pokfulam, Hong Kong, SAR, China.
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Desmopressin improves platelet function in uremic patients taking antiplatelet agents who require emergent invasive procedures. Ann Hematol 2015; 94:1457-61. [DOI: 10.1007/s00277-015-2384-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 04/15/2015] [Indexed: 10/23/2022]
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Mavani GP, DeVita MV, Michelis MF. A review of the nonpressor and nonantidiuretic actions of the hormone vasopressin. Front Med (Lausanne) 2015; 2:19. [PMID: 25853137 PMCID: PMC4371647 DOI: 10.3389/fmed.2015.00019] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/09/2015] [Indexed: 01/02/2023] Open
Abstract
The pressor and antidiuretic actions of arginine vasopressin (AVP) have been well documented. This review focuses on the less widely appreciated actions of AVP which also have important physiologic functions and when better understood may provide important insights into common disease states. These actions include effects on pain perception and bone structure as well as important relationships to the varied components of metabolic syndrome. These include effects on blood glucose, lipid levels, and blood pressure. AVP may also play a role in the progression of chronic kidney disease and effect physiologic changes relating to aging, abnormal social behavior, and cognitive function. Important cellular responses including cell proliferation, inflammation, and control of infection and their relationship to AVP are described. Finally, the effects of AVP on hemostasis and the hypothalamic-pituitary-adrenal axis are noted. The goal of this summary of the various actions of AVP is to direct attention to the potential benefits of research in these underemphasized areas of importance.
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Affiliation(s)
- Gaurang P Mavani
- Division of Nephrology, Department of Medicine, Lenox Hill Hospital , New York, NY , USA
| | - Maria V DeVita
- Division of Nephrology, Department of Medicine, Lenox Hill Hospital , New York, NY , USA
| | - Michael F Michelis
- Division of Nephrology, Department of Medicine, Lenox Hill Hospital , New York, NY , USA
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Peck-Radosavljevic M, Angeli P, Cordoba J, Farges O, Valla D. Managing complications in cirrhotic patients. United European Gastroenterol J 2015; 3:80-94. [PMID: 25653862 DOI: 10.1177/2050640614560452] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/21/2014] [Indexed: 12/13/2022] Open
Abstract
Liver cirrhosis is a serious and potentially life-threatening condition. This life-threatening condition usually arises from complications of cirrhosis. While variceal bleeding is the most acute and probably best studied, several other complications of liver cirrhosis are more insidious in their onset but nevertheless more important for the long-term management and outcome of these patients. This review summarizes the topics discussed during the UEG-EASL Hepatology postgraduate course of the United European Gastroenterology Week 2013 and discusses emergency surgical conditions in cirrhotic patients, the management of hepatic encephalopathy, ascites and hepatorenal syndrome, coagulation disorders, and liver cancer.
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Affiliation(s)
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, University of Padova, Italy
| | - Juan Cordoba
- Liver Unit, Hospital Valld'Hebron, Barcelona, Spain
| | - Oliver Farges
- Department of HPB surgery HôpitalBeaujon, AP-HP, Université Paris-Diderot, Clichy-la-Garenne, France
| | - Dominique Valla
- Service d'Hépatologie, HôpitalBeaujon, AP-HP, Université Paris-Diderot, Clichy-la-Garenne, France
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Wafa K, Lehmann C, Wagner L, Drzymulski I, Wegner A, Pavlovic D. Desmopressin improves intestinal functional capillary density and decreases leukocyte activation in experimental endotoxemia. Microvasc Res 2015; 97:98-104. [DOI: 10.1016/j.mvr.2013.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 08/27/2013] [Accepted: 09/05/2013] [Indexed: 12/16/2022]
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Abstract
In patients with cirrhosis, routine laboratory tests for primary hemostasis and coagulation usually show anomalies that are associated with excess bleeding in other settings, in particular low platelet counts and prolonged prothrombin time. However, under conditions similar to those in vivo, primary hemostasis and thrombin production do not appear to be decreased in patients with cirrhosis, particularly when the platelet count is above 75,000/μl. Furthermore, there is laboratory and epidemiological evidence of a mild procoagulant and prothrombotic state in patients with cirrhosis. Bleeding is mainly because of portal hypertension rather than defective hemostasis. There is some evidence that anticoagulation therapy is not associated with an excess of severe bleeding and that it could improve the outcome in patients without portal vein thrombosis. At present, there is no clear evidence that portal vein thrombosis is responsible for the progression of liver disease and that anticoagulation therapy would improve the outcome of patients with portal vein thrombosis.
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Affiliation(s)
- Dominique-C Valla
- DHU UNITY, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy-la-Garenne, France; INSERM, U1149, CRI, Université Paris-Diderot, Paris, France
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Al-Jafar H, Al-Barjas H, Hashem RA, Refaii TMK, AlSaeed AM. Successful management of severe refractory acquired immune bleeding disorder: Prior to insisting surgery. Int J Surg Case Rep 2014; 5:1186-9. [PMID: 25437672 PMCID: PMC4275849 DOI: 10.1016/j.ijscr.2014.09.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 09/17/2014] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Acquired bleeding disorders are rare and may be missed before surgery. Additionally, they may be refractory to conventional treatments. PRESENTATION OF CASE A 50-year-old patient experienced prolonged post-operative bleeding when his bleeding disorder was missed prior to his undergoing inguinal herniorrhaphy. Post-operative investigations revealed severe acquired von Willebrand syndrome associated with a monoclonal gammopathy of undetermined significance. A few months later, he required umbilical herniorrhaphy, but he did not respond to attempts to raise his von Willebrand factor antigen and activity levels using conventional therapies, including desmopressin, cryoprecipitate, intravenous immunoglobulin, and Von Willebrand factor concentrate. A triple therapy combination of dexamethasone, intravenous immunoglobulin, and mycophenolate mofetil was administered, with a successful and sustained response, lasting about 2 months. The surgery was performed safely, without any complications. DISCUSSION Conventional acquired von Willebrand syndrome treatment is usually aimed at replacing von Willebrand factor or stimulating its secretion from storage in endothelial cells. In the present case, the alternative treatment was directed against both the humoral and cell-mediated immune mechanisms. CONCLUSION This case of acquired bleeding disorder showed that more attention must be given to a patient's coagulation profile, even if only very minor laboratory coagulation derangements are detected prior to surgery, to avoid missing such rare disorders. The described triple therapy demonstrated good effects and may be considered for inclusion in a controlled randomized study to determine its usefulness for other surgeries delayed due to severe acquired bleeding disorders. To the best of our knowledge, this triple combination treatment has not been previously used for the treatment of severe acquired bleeding disorders that are refractory to conventional therapies.
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Affiliation(s)
- Hassan Al-Jafar
- Department of Hematology, Amiri Hospital, Kuwait City, Kuwait.
| | - H Al-Barjas
- Department of Surgery, Amiri Hospital, Kuwait City, Kuwait.
| | - Raed A Hashem
- Department of Emergency Medicine and Trauma, Amiri Hospital, Kuwait City, Kuwait.
| | - Thanaa M K Refaii
- Department of Clinical Chemistry, Amiri Hospital, Kuwait City, Kuwait.
| | - Ahmad M AlSaeed
- Department of Pharmacy, Amiri Hospital, Kuwait City, Kuwait.
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Anandagoda N, Jayawardene S, Macdougall IC, Shah S. Desmopressin use prior to renal transplant biopsy-does it fit? Clin Kidney J 2014; 7:602-4. [PMID: 25859381 PMCID: PMC4389145 DOI: 10.1093/ckj/sfu110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 10/03/2014] [Indexed: 11/24/2022] Open
Abstract
Desmopressin acetate (DDAVP), a selective agonist of type 2 vasopressin receptors, is sometimes used prior to percutaneous renal biopsy to reduce the risk of bleeding complications. DDAVP increases free water reabsorption in renal collecting ducts, potentially leading to water intoxication or dilutional hyponatraemia. We present two cases, where DDAVP was used prior to percutaneous renal transplant biopsy and was associated with severe hyponatraemia and neurological sequelae. With DDAVP being advocated in many centres prior to percutaneous renal biopsy, these cases highlight the need for increased awareness regarding side effects. In this report, we provide suggestions on strategies to minimize hyponatraemia in this context.
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Affiliation(s)
| | | | | | - Sapna Shah
- Renal Unit , King's College Hospital , London , UK
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Radhakrishnan S, Chanchlani R, Connolly B, Langlois V. Pre-Procedure Desmopressin Acetate to Reduce Bleeding in Renal Failure: Does It Really Work? ACTA ACUST UNITED AC 2014; 128:45-8. [DOI: 10.1159/000362455] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 03/24/2014] [Indexed: 11/19/2022]
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Nishant, Kumari R. Surgical management in treatment of Jehovah's witness in trauma surgery in Indian subcontinent. J Emerg Trauma Shock 2014; 7:215-21. [PMID: 25114433 PMCID: PMC4126123 DOI: 10.4103/0974-2700.136868] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 10/29/2013] [Indexed: 12/22/2022] Open
Abstract
The Jehovah's Witness religion is a Christian movement, founded in the US in the 1870s, with 7 million followers worldwide with only 0.002% in India. There is minimal to complete absence of awareness about the existence of this community in our society. Astonishing is that fact that among medical professionals, there is almost no awareness about this unique population, regarding the fact that they completely refuse of blood transfusion even if it leads to their death. This is integral to their faith. Besides legal and ethical issues in treating these group of patients, the biggest challenge exist even in the western world is their management in trauma scenario where few options exist. We have discussed the issues and recommendations in management in trauma scenario in our Indian subcontinent.
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Affiliation(s)
- Nishant
- Department of Orthopedics and Spine Services, Rameshwaram Clinic, Patna, Bihar, India
| | - Renu Kumari
- Department of Ear, Nose and Throat, Rameshwaram Clinic, Patna, Bihar, India
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Desmopressin in treatment of haematological disorders and in prevention of surgical bleeding. Blood Rev 2014; 28:95-102. [DOI: 10.1016/j.blre.2014.03.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 03/11/2014] [Indexed: 02/05/2023]
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