Management of bleeding complications in the anticoagulated patient

A new era of stroke prevention in atrial fibrillation: comparing a new generation of oral anticoagulants with warfarin

Traditionally, warfarin has been used to prevent stroke in patients with atrial fibrillation (AF), but data from large, multinational, prospective, randomized studies suggest that novel oral anticoagulants (NOACs) may be suitable alternatives. These include the direct thrombin inhibitor dabigatran and the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban. These data showed that dabigatran 150 mg twice daily was more effective at preventing stroke than warfarin, with similar rates of major bleeding, while rivaroxaban 20 mg once daily was noninferior to warfarin, with no difference in major bleeding rates. In addition, apixaban 5 mg twice daily was shown to be superior to warfarin for preventing stroke, with lower bleeding rates. Currently, edoxaban is still in clinical trials. NOACs offer more predictable anticoagulant effects than warfarin and do not require regular monitoring; however, different NOACs are associated with varied drug interactions and limitations related to use in certain patient populations. Overall, the clinical data suggest that these novel agents will offer new options for stroke prevention in patients with AF.

The neuro-critical care management of the endovascular stroke patient

OPINION STATEMENT

Acute ischemic stroke carries high morbidity and mortality. The advent of intravenous thrombolysis and endovascular reperfusion techniques have helped improve clinical outcomes for patients with large vessel acute ischemic stroke. The care of the post-endovascular stroke patient is complex and encompasses almost all aspects of medicine. Hemodynamics should be optimized post procedure to ensure adequate cerebral perfusion and strict hemodynamic parameters must be adhered to minimize reperfusion injury. Though no studies have specifically examined hemodynamic goals, our practice is to maintain a mean arterial pressure (MAP) > 70 and systolic blood pressure (SBP) < 140 for patients following successful recanalization. Early anti-thrombotic therapy is indicated in patients with stent placement. It remains less clear which patients may benefit from additional anticoagulation or therapy with IIb/IIIa inhibitors. Careful consideration must be paid to volume status to reduce risk of contrast nephropathy and maximize cerebral perfusion. Oral care and attention to dysphagia are key in preventing aspiration pneumonia. Glycemic control should be optimized to avoid excessive hyper and hypoglycemia. In the absence of data to guide treatment of anemia, our practice is to transfuse asymptomatic anemia when Hgb < 7 mg/dL, or if the patient is symptomatic or hemodynamically unstable. Neuro-protective strategies should be considered in the context of clinical trials until further studies are complete. At a minimum, fever should be treated aggressively. Young patients with good pre-morbid functional status who continue to have large volume infarcts may benefit from decompressive hemicraniectomy. When appropriate, aggressive and early mobilization is recommended to prepare patients for acute rehabilitation. Because randomized prospective data is lacking, patients should be encouraged to enroll in clinical trials to optimize care of this growing patient population.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?» All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.

[The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]

Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: "Does this particular AABT reduce the transfusion rate or not?" All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.