Emergency management of patients with bleeding disorders: Practical points for the emergency physician

Diagnostic yield of bone marrow aspiration in paediatric primary immune thrombocytopenia: impact of evolution and adherence to medical guidelines over the last 25 years

The aim of this study is to analyse the diagnostic value of bone marrow aspiration (BMA) in a retrospective cohort of patients with suspected immune thrombocytopaenia (ITP). We further measure changes in the percentage of patients who underwent this study and whether testing or not was in accordance with current guidelines at the time of diagnosis. We conducted a chart review of 243 patients with ITP who underwent follow-up in our institution between 1995 and 2022. The patients were divided into historical cohorts based on the practice guidelines of the Spanish Society of Pediatric Hematology and Oncology (SEHOP) and the American Society of Hematology (ASH) in place at the time of follow-up. For each case, time of disease presentation or initial diagnosis was defined as that which occurred in the first 72 h following disease onset. Based on data from the historical cohorts studied, we observed a lower total number of BMAs at diagnosis over time (p < 0.005). A gradual reduction was seen in the number of BMAs with the introduction of guidelines, including a progressively lower number of BMAs performed without indication (p < 0.05). Subsequent to the initial diagnosis, the procedure played a decisive role in only 2 patients (0.58%), allowing for a diagnosis of acquired aplastic anaemia in both cases. In both of them on diagnosis, BMA did not appear to be indicated, although subsequent analysis after 72 h raised suspicion of bone marrow failure.

CONCLUSION

BMA at presentation did not significantly alter the diagnosis in our cohort of patients with an initial suspicion of ITP, although the procedure was decisive in diagnosing 2 cases of acquired aplastic anaemia during the subsequent course of the disease. Regarding the number of aspirations performed, our findings show that increased physician compliance with current guidelines reduced the rate of unnecessary BMAs.

WHAT IS KNOWN

• BMA is a supplementary test for the diagnosis of ITP. • The usefulness of this invasive diagnostic procedure is not clearly stated in current guidelines.

WHAT IS NEW

• Adjustments to scientific guidelines have led to a reduction in the number of BMAs performed on our patients with suspected ITP in the last 27 years. • While the risks and benefits of BMA at the time of diagnosis are unclear in patients with suspected ITP, the procedure does not contribute significant information to support the diagnosis.

Hemostasis Testing in the Emergency Department: A Narrative Review

Routine laboratory screening is typically performed at initial evaluation of the vast majority of presentations to the emergency department (ED). These laboratory results are crucial to the diagnostic process, as they may influence up to 70% of clinical decisions. However, despite the usefulness of biological assessments, many tests performed are inappropriate or of doubtful clinical relevance. This overutilization rate of laboratory testing in hospitals, which represents a significant medical-economic burden, ranges from 20 to 67%, with coagulation tests at the top of the list. While reviews frequently focus on nonintensive care units, there are few published assessments of emergency-specific interventions or guidelines/guidance to date. The aim of this review is to highlight current recommendations for hemostasis evaluation in the emergency setting with a specific analysis of common situations leading to ED admissions, such as suspected venous thrombosis or severe bleeding. We revisit the evidence related to the assessment of patient's hemostatic capacity based on comprehensive history taking and physical examination as well as best practice recommendations for blood sample collection to ensure the reliability of results. This review also includes an examination of various currently available point of care tests and a comprehensive discussion on indications, limitations, and interpretation of these tests.

Emergency Nursing Countermeasures and Experience of Patients with Primary Liver Cancer Nodule Rupture and Hemorrhage

Objective

To explore the emergency nursing countermeasures and nursing experience of patients with primary liver cancer nodule rupture and hemorrhage.

Methods

30 patients with primary liver cancer nodule rupture and hemorrhage treated in our hospital since January 2020 after the implementation of emergency nursing countermeasures were selected as the observation group, and another 30 patients with primary liver cancer nodule rupture and hemorrhage treated in our hospital before January 2020 were selected as the control group. The control group received basic nursing intervention, while the observation group received emergency nursing measures. The hemoglobin level, blood oxygen saturation monitoring value, and partial pressure of oxygen of patients with hemorrhagic shock due to nodular rupture of primary liver cancer were compared between the two groups at admission and after nursing care. All indexes of patients during the perioperative period were recorded. The incidence of complications, mortality, and nursing satisfaction rates of the patients' families were compared between the two groups.

Results

After nursing care, the observation group's patients' hemoglobin level, blood oxygen saturation monitoring value, and partial pressure of oxygen were higher than those of the control group's patients (P < 0.05). The intraoperative bleeding volume, shock correction time, and discharge time of patients in the observation group were lower than those of patients in the control group (P < 0.05). The incidence of complications and mortality in the observation group was significantly lower than those in the control group (P < 0.05). The nursing satisfaction rate of patients in the observation group was higher than that of the control group (P < 0.05).

Conclusion

The results of emergency nursing intervention in patients with primary liver cancer rupture and hemorrhage are reliable, which can significantly improve perioperative indicators of patients, reduce complications and mortality, improve nursing satisfaction, and effectively shorten the hospital stay of patients.

Portuguese Consensus and Recommendations for Acquired Coagulopathic Bleeding Management (CCBM)

We aimed to determine how Portuguese physicians handle major bleeding. We also aim to establish global diagnostic and therapeutic recommendations to be followed in clinical practice by using a step-wise approach of evidence generation. This study followed a three-step process: a steering committee desk review, a Delphi technique, an expert panel meeting. A modified 3-round Delphi including 31 statements was performed. Questions were answered in a five-point Likert-type scale. Consensus threshold was established as a percentage of agreement among participants ≥90% in the first round, and ≥85% in the second and third rounds. The level of consensus achieved by panelists was discussed with the scientific committee (January-2020). Fifty-one physicians participated in the study (compliance rate >90%). Analyzing the three rounds, consensus was reached on 20 items (64.5%) in the first, 4/11 items (36.4%) in the second and 6/7 items (85.7%) in the third. One statement about administration of clotting factor concentrates for bleeding control did not reach consensus. A high level of consensus was reached toward the need for implementing Patient Blood Management strategies in Portuguese hospitals, reduce exposure to allogeneic blood components, to use goal directed therapies for acquired bleeding management, and the need for evaluating blood transfusion indirect costs. A final version with 12 recommendations was built, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Our results provide critically appraised and updated evidence on bleeding coagulopathies management in Portugal. Additional studies, mainly about indirect costs of blood transfusion, are needed.