Antithrombotic Reversal Agents

Management of the Jehovah's Witness in Obstetrics and Gynecology: A Comprehensive Medical, Ethical, and Legal Approach

IMPORTANCE

Obstetricians and gynecologists frequently deal with hemorrhage so they should be familiar with management of patients who refuse blood transfusion. Although there are some reports in the literature about management of Jehovah's Witness patients in obstetrics and gynecology, most of them are case reports, and a comprehensive review about these patients including ethicolegal perspective is lacking.

OBJECTIVE

This review outlines the medical, ethical, and legal implications of management of Jehovah's Witness patients in obstetrical and gynecological settings.

EVIDENCE ACQUISITION

A search of published literature using PubMed, Ovid Medline, EMBASE, and Cochrane databases was conducted about physiology of oxygen delivery and response to tissue hypoxia, mortality rates at certain hemoglobin levels, medical management options for anemic patients who refuse blood transfusion, and ethical/legal considerations in Jehovah's Witness patients.

RESULTS

Early diagnosis of anemia and immediate initiation of therapy are essential in patients who refuse blood transfusion. Medical management options include iron supplementation and erythropoietin. There are also some promising therapies that are in development such as antihepcidin antibodies and hemoglobin-based oxygen carriers. Options to decrease blood loss include antifibrinolytics, desmopressin, recombinant factor VII, and factor concentrates. When surgery is the only option, every effort should be made to pursue minimally invasive approaches.

CONCLUSION AND RELEVANCE

All obstetricians and gynecologists should be familiar with alternatives and "less invasive" options for patients who refuse blood transfusions.

"Early Trigger" Intravenous Vitamin K: Optimizing Target-Driven Care in Warfarinised Patients With Hip Fracture

Best practice tariff (BPT) was introduced as a financial incentive model to improve compliance with evidence-based care, such as operation for hip fracture within 36 hours of admission. We previously evaluated the impact of warfarin on patients with hip fracture, revealing significant delay to operation and subsequent loss of revenue. As a result of this, an “early trigger” intravenous vitamin K (IVK) pathway was introduced and the service reaudited a year later. The first cycle was a retrospective audit of all cases with hip fracture against BPT standards over a 32-month period. Subsequent protocol change resulted in all warfarinised cases being given 2 mg IVK in the emergency department prior to blood testing. This protocol was reaudited against the same BPT standards 12 months later. An intention-to-treat approach was used, despite breaches of protocol and other reasons for patients not progressing to theater. The data were analyzed with parametric tools to establish true clinical and statistical impact of the introduction of the protocol. In the first cycle, 80 patients were admitted on warfarin with a mean time to theater of 53.71 hours. Of these patients, 79% breached BPT due to anticoagulation. Twelve months following protocol introduction, 42 patients had a mean time to theater of 37.61 hours. Of these patients, 34% breached BPT due to anticoagulation. These data are both clinically and statistically significant (P < .001). No adverse events occurred. We have shown for the first time that “early-trigger” IVK can reduce delay to theater and maximize tariff payments in warfarinised patients with hip fracture. This is in addition to other established benefits associated with early surgery such as decreasing risk of pressure lesions and pneumonia. It affords high-quality patient-centered care while ensuring trauma units achieve maximal financial reimbursement through pay for improved performance and supports a culture of change behavior.

The clinical management of acute intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a stroke subtype with high mortality and significant disability among survivors. The management of ICH has been influenced by the results of several major trials completed in the last decade. It is now recognized that hematoma expansion is a major cause of morbidity and mortality. However, efforts to improve clinical outcome through mitigation of hematoma expansion have so far been unsuccessful. Acute blood pressure management has recently been shown to be safe in the setting of acute ICH but there was no reduction in mortality with early blood pressure (BP) lowering. Two large trials of surgical evacuation of supratentorial ICH have not shown improvement in outcome with surgery, thus minimally invasive surgical strategies are currently being studied. Lastly, a better understanding of the pathophysiology of ICH has led to the identification of several new mechanisms of injury that could be potential therapeutic targets.