Consensus conference on platelet transfusion. Final statement

Management of Hemorrhage Related to Direct Action Oral Anticoagulant Medication

Introduction: Direct Oral Anticoagulant – DOACs) are a new class of anticoagulant that directly inhibit the trombine (dabigatran) or Xa factor (rivaroxabane , edoxabane and apixabane) in the coagulation cascade. These medications are being more frequently used for the treatment and prevention of thrombolytic events, mainly in patients with atrial fibrillation, in substitute to varfrine or other vitamin K antagonists (VKAs). Although the incidence of hemorrhage is higher in AVKs than in DOACs, these events may also occur in this group, even in the form of intracranial hemorrhage (ICH), with risk of death. Nowadays, DOACs indications have progressively enhanced and the availability of their specific reverse agents certainly will enhance the safety of their usage. Idarucizumab, reverse agent of dabigatrane, and alpha andexanet, reverse agent of Xa factor, have been approved by the Food and Drug Administration in the United States and ciraparantag may be approved in a near future. Objective: To review the literature on the manage of hemorrhage related to the use of DOACs. Methods: Review of literature that used articles from 1998 to 2017, from several platforms and journals. Conclusion: DOACs constitute a great advance in prophylaxis and treatment of thrombolytic diseases, which presents elevated morbidymortality, and hemorrhages are the main adverse events related to their usage, being rarely necessary the immediate reverse of the anticoagulation. However, the existence of DOACs specific reverse agents enhance the safety of patients, whose anticoagulation may be rapidly reversed if necessary.

Manejo das Hemorragias Relacionadas aos Anticoagulantes Orais de Ação Direta

Introdução: Os anticoagulantes orais diretos (direct oral anticoagulant – DOACs) são uma nova classe de anticoagulantes que inibem diretamente a trombina (dabigatrana) ou o fator Xa (rivaroxabana, edoxabana e apixabana) na cascata da coagulação. Esses estão sendo cada vez mais utilizados para tratamento e prevenção de eventos tromboembólicos, principalmente em pacientes com fibrilação atrial, em substituição à varfarina ou outros antagonistas de vitamina K (AVKs). Embora a incidência de hemorragias seja maior nos AVKs do que nos DOACs, elas também podem ocorrer nesse grupo, até mesmo na forma de hemorragia intracraniana (HIC) com risco de morte. Atualmente as indicações dos DOACs vêm aumentando progressivamente, e a disponibilização de seus agentes reversores específicos certamente aumentará a segurança e, consequentemente, sua utilização. O idarucizumab, reversor da dabigatrana, e o andexanet alfa, reversor dos inibidores do fator Xa, foram aprovados pelo Food and Drug Administration (FDA) dos Estados Unidos e o ciraparantag poderá ser aprovado em um futuro próximo. Objetivo: Revisar a literatura sobre o manejo da hemorragia relacionada ao uso dos DOACs. Métodos: Revisão da literatura que utilizou artigos de 1998 a 2017, de diversas plataformas e revistas. Conclusão: Os DOACs constituem um grande avanço na profilaxia e tratamento da doença tromboembólica, que cursa com elevada morbimortalidade, e as hemorragias são os principais eventos adversos relacionados ao seu uso, sendo raramente necessária a reversão imediata da anticoagulação. No entanto, a existência dos reversores específicos dos DOAcs aumenta a segurança dos pacientes, que poderão ter sua anticoagulação revertida rapidamente, se necessário.

Acute bleeding complications in patients after hematopoietic stem cell transplantation with prophylactic platelet transfusion triggers of 10�נ109and 20�נ109per L

BACKGROUND

Prophylactic platelet (PLT) transfusions are given as a standard care in patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HSCT). This retrospective analysis evaluates utilization of blood transfusions, risk of bleeding, and survival in 480 HSCT patients at 10 x 10(9) and 20 x 10(9) per L prophylactic trigger levels.

STUDY DESIGN AND METHODS

A total of 224 patients received prophylactic PLT transfusions at 20 x 10(9) per L threshold (1997-1998, SP1); 256 patients had prophylaxis at 10 x 10(9) per L (1999-2001, SP2). Bleeding scores were assigned daily.

RESULTS

A slight reduction in PLT transfusions per patient in SP2 compared with SP1 was not statistically significant (odds ratio, 0.82; 95% confidence interval, 0.51-1.33; p = 0.416), yet a significantly higher proportion of patients in SP2 had PLT counts less than or equal to 10 x 10(9) per L compared to SP1 (p < 0.001). In patients who bled, however, there was no excess exposure to low PLT counts before bleeding started. A substantial number of patients who bled received PLT transfusions above the goal before bleeding started (82.9% in SP2, 41.5% in SP1) because of medical complications that associated with increased risk of bleeding. Bleeding incidence was similar in both study periods (21.9% in SP1, 16.4% in SP2; p = 0.526). Bleeding was significantly associated with reduced survival in both study periods.

CONCLUSIONS

Patients who bled were usually placed on a higher threshold before the onset of their major bleeding event and were not exposed to additional risk of bleeding from thrombocytopenia. Similarity in bleeding incidence between study periods appears to associate with adjustments to high-risk conditions and may not reflect consequences of the lower transfusion threshold.

'Last-ditch' use of recombinant factor VIIa in patients with massive haemorrhage is ineffective

BACKGROUND AND OBJECTIVES

The aim of this retrospective study was to assess the effect of activated recombinant factor VII (rFVIIa) on the natural history of massive transfusion episodes.

MATERIALS AND METHODS

During 2002, outcome parameters were assessed in 50 patients transfused with more than 10 units of packed red cells. The effect of the addition of rFVIIa in 10 patients, with intractable bleeding, was then observed.

RESULTS

Overall mortality was 20% at 24 h and 34% at 7 days. Severe coagulopathy was confirmed as a serious negative prognostic factor and occurred in 42% of patients overall, but in 70% of rFVIIa-treated patients. Transient cessation or reduction of bleeding was noted in 60% of patients following rFVIIa infusion. However, 24-h and 7-day mortality rates were 40% and 70%, respectively, in this group.

CONCLUSIONS

Last-ditch rFVIIa therapy in patients resistant to conventional treatment did not rescue these patients or significantly alter outcomes.

Management of massive blood loss: a template guideline

The management of acute massive blood loss is considered and a template guideline is formulated, supported by a review of the key literature and current evidence. It is emphasized that, if avoidable deaths are to be prevented, surgeons, anaesthetists, haematologists and blood-bank staff need to communicate closely in order to achieve the goals of secure haemostasis, restoration of circulating volume, and effective management of blood component replacement.