Transfusion-sparing hemostatic agents

Antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease

BACKGROUND

Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. People with liver disease frequently have haemostatic abnormalities such as hyperfibrinolysis. Therefore, antifibrinolytic amino acids have been proposed to be used as supplementary interventions alongside any of the primary treatments for upper gastrointestinal bleeding in people with liver diseases. This is an update of this Cochrane review.

OBJECTIVES

To assess the beneficial and harmful effects of antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Controlled Trials Register (February 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 2 of 12, 2015), MEDLINE (Ovid SP) (1946 to February 2015), EMBASE (Ovid SP) (1974 to February 2015), Science Citation Index EXPANDED (1900 to February 2015), LILACS (1982 to February 2015), World Health Organization Clinical Trials Search Portal (accessed 26 February 2015), and the metaRegister of Controlled Trials (accessed 26 February 2015). We scrutinised the reference lists of the retrieved publications.

SELECTION CRITERIA

Randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. Observational studies for assessment of harms.

DATA COLLECTION AND ANALYSIS

We planned to summarise data from randomised clinical trials using standard Cochrane methodologies and assessed according to the GRADE approach.

MAIN RESULTS

We found no randomised clinical trials assessing antifibrinolytic amino acids for treating upper gastrointestinal bleeding in people with acute or chronic liver disease. We did not identify quasi-randomised, historically controlled, or observational studies in which we could assess harms.

AUTHORS' CONCLUSIONS

This updated Cochrane review identified no randomised clinical trials assessing the benefits and harms of antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease. The benefits and harms of antifibrinolytic amino acids need to be tested in randomised clinical trials. Unless randomised clinical trials are conducted to assess the trade-off between benefits and harms, we cannot recommend or refute antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver diseases.

Antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease

BACKGROUND

Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. Patients with liver disease frequently have haemostatic abnormalities like hyperfibrinolysis. Therefore, antifibrinolytic amino acids have been proposed to be used as supplementary interventions alongside any of the primary treatments for upper gastrointestinal bleeding in patients with liver diseases.

OBJECTIVES

To assess the beneficial and harmful effects of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register (11 June 2012), Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2012, Issue 5 of 12), MEDLINE (Ovid SP) (1946 to June 2012), EMBASE (Ovid SP) (1974 to June 2012), Science Citation Index EXPANDED (1900 to June 2012), LILACS (1982 to June 2012), Clinical Trials Search Portal of the WHO (accessed June 18, 2012), and the Metaregister of Controlled Trials (accessed June 18, 2012). We scrutinised the reference lists of the retrieved publications.

SELECTION CRITERIA

Randomised clinical trials irrespective of blinding, language, or publication status for assessment of benefits and harms. Observational studies for assessment of harms.

DATA COLLECTION AND ANALYSIS

Data from randomised clinical trials were to be summarised by standard Cochrane Collaboration methodologies.

MAIN RESULTS

We could not find any randomised clinical trials assessing antifibrinolytic amino acids for treating upper gastrointestinal bleeding in patients with acute or chronic liver disease. We could not identify quasi-randomised, historically controlled, or observational studies in which we could assess harms.

AUTHORS' CONCLUSIONS

No randomised clinical trials assessing the benefits and harms of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease were identified. The benefits and harms of antifibrinolytic amino acids need to be tested in randomised clinical trials. Unless randomised clinical trials are conducted to assess the trade off between benefits and harms, we cannot recommend nor refute antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver diseases.

Use of Blood Products

Patients in the pediatric intensive care unit (PICU) frequently receive transfusions of blood products. While these therapies are often beneficial, they can be associated with significant, yet often overlooked, risks. Clinical guidelines for blood product transfusions must be well defined in order to prevent misuse of this limited resource. It is important for the intensivist to have a thorough understanding of the indications for specific blood products, and the transfusion needs of particular patient populations.

A benefit-risk review of systemic haemostatic agents: part 1: in major surgery

Systemic haemostatic agents play an important role in the management of blood loss during major surgery where significant blood loss is likely and their use has increased in recent times as a consequence of demand for blood products outstripping supply and the risks associated with transfusions. Their main application is as prophylaxis to reduce bleeding in major surgery, including cardiac and orthopaedic surgery and orthotopic liver transplantation. Aprotinin has been the predominant agent used in this setting; of the other antifibrinolytic agents that have been studied, tranexamic acid is the most effective and epsilon-aminocaproic acid may also have a role. Eptacog alfa (recombinant factor VIIa) has also shown promise. Tranexamic acid, epsilon-aminocaproic acid and eptacog alfa are generally well tolerated; however, when considering the methods to reduce or prevent blood loss intra- and postoperatively, the benefits of these agents need to be weighed against the risk of adverse events. Recently, concerns have been raised about the safety of aprotinin after an association between increased renal dysfunction and mortality was shown in retrospective observational studies and an increase in all-cause mortality with aprotinin relative to tranexamic acid or epsilon-aminocaproic acid was seen after a pre-planned periodic analysis of the large BART (Blood conservation using Antifibrinolytics in a Randomized Trial) study. The latter finding resulted in the trial being halted, and aprotinin has subsequently been withdrawn from the market pending detailed analysis of efficacy and safety results from the study. Part 1 of this benefit-risk review examines the efficacy and adverse effect profiles of systemic haemostatic agents commonly used in surgery, and provides individual benefit-risk profiles that may assist clinicians in selecting appropriate pharmacological therapy in this setting.

Haemorrhagic shock therapy

BACKGROUND

Severe injury is often associated with haemorrhagic shock and this is the most common cause of preventable mortality after injury. Care of the injured patient in shock involves an overlapping continuum of care beginning during the prehospital phase of care and extending through the interventional and critical care phases.

OBJECTIVE

This study aimed to review emerging therapies in the treatment of haemorrhagic shock.

METHODS

A review of recent clinical articles (1996 - 2007) examining therapeutic measures for haemorrhagic shock treatment was undertaken.

CONCLUSIONS

Although the mainstay of therapy continues to be obtaining haemostasis and restoring tissue perfusion, a multitude of novel strategies are emerging, including advanced haemostatic agents, hypertonic resuscitation and massive transfusion protocols, as well as blood substitutes and an improved understanding of damage control principles, thereby allowing increased survival and improved outcomes in the severely injured patient with major haemorrhage.

Management of thrombocytopenia in bone marrow failure: a review

The clinical course of many neoplastic and primary bone marrow diseases will result in cytopenias secondary to bone marrow failure or infiltration. Acute and chronic leukemias, the myelodysplastic syndromes (MDS), aplastic anemia, breast and prostate cancer, as well as other hematologic and solid tumors, all may lead to chronic, severe cytopenias. Management of anemia and neutropenia are well described in the medical literature. Less well detailed are management approaches for patients with chronic thrombocytopenia, with or without active bleeding. Severe thrombocytopenia presents many difficult management choices for caregivers, patients and their families, especially near the end of life. The use of platelet transfusions in this patient population presents complex issues; platelets are logistically more difficult to transfuse than red cells and carry risks including acute febrile episodes, alloimmunization, and infection. In this review, we discuss the association of chronic thrombocytopenia to serious bleeding and the role of various prophylactic and therapeutic interventions available to palliative care and hospice providers. Specifically, this review examines the following issues: What is the morbidity and mortality from chronic thrombocytopenia in the setting of cancer or other bone marrow failure states? Is there a role for prophylactic platelet transfusions in the palliative care setting, and if so, with what frequency of monitoring, and at what transfusion threshold? What is the impact of alloimmunization and how can it be minimized? What treatments are available besides, or in addition to, platelet transfusions for acute bleeding episodes?

Antifibrinolytic amino acids for acquired coagulation disorders in patients with liver disease

BACKGROUND

Upper gastrointestinal bleeding is one of the most frequent causes of morbidity and mortality in the course of liver cirrhosis. Patients with liver disease frequently have haemostatic abnormalities, which include accelerated fibrinolysis. Several primary treatments are used for upper gastrointestinal bleeding in patients with liver diseases. Supplementary interventions are often used as well. One of them could be antifibrinolytic amino acids administration.

OBJECTIVES

To assess the beneficial and harmful effects of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease plus acquired coagulation disorders.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (March 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 1, 2006), MEDLINE (1950 to March 2006), EMBASE (1980 to March 2006), Science Citation Index EXPANDED (1945 to March 2006), LILACS (1982 to March 2006), ClinicalTrials.gov (at www.clinicaltrials.gov) (accessed August 2006), ISI Web of Science (April 2006), and the International Standard Randomised Controlled Trial Number Register (at http://controlled-trials.com/isrctn/search.asp) (accessed August 2006). We also checked the reference lists of all the trials identified by the above methods.

SELECTION CRITERIA

We searched for randomised clinical trials irrespective of blinding, language, or publication status.

DATA COLLECTION AND ANALYSIS

We intended to summarise data by standard Cochrane Collaboration methodologies.

MAIN RESULTS

We could not find any randomised clinical trials with antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with acute or chronic liver disease plus acquired coagulation disorders.

AUTHORS' CONCLUSIONS

We were unable to identify randomised clinical trials on the safety and efficacy of antifibrinolytic amino acids for upper gastrointestinal bleeding in patients with liver disease (acute or chronic) plus acquired coagulation disorders. The effects of antifibrinolytic amino acids has to be tested in randomised clinical trials.

Quality Assurance Assessment of the Use of Linezolid in the Treatment of Thermal Injury Patients at a Community Teaching Hospital

We sought to evaluate the adverse effect profile of linezolid among thermal injury patients requiring treatment for Enterococcus species or other Gram-positive infection warranting treatment with linezolid. Seventy-six inhalation injury and/or thermal injury patients experiencing 94 exposures to linezolid for 48 hours or longer (range, 2-83 days) were included. We evaluated leukocyte count and platelet count for the time period preceding, during, and after therapy with linezolid based on specified time periods of exposure for evaluation of specific adverse effects. Sixty-three of 76 (83%) patient admissions were complicated by inhalation injury. The average TBSA involvement was 34.4% (range, 0-98%). The onset of thrombocytopenia before linezolid therapy was noted in 21 of 57 patients (36.8%), which was attributable to fluid resuscitation and acute platelet consumption. After they were exposure to linezolid, 12 patients developed thrombocytopenia. Platelet counts recovered in 7 of these 12 patients with continued exposure to linezolid; however, thrombocytopenia persisted for more than 9 days after therapy in 9 patients, of whom 6 patients succumbed to sepsis. On average, thrombocytes increased by 102,000/mm3 during linezolid treatment. Leucopenia was rare in thermal injury patients, and persisting thrombocytopenia in this population was associated with sepsis and mortality. Continuing linezolid therapy after the onset of thrombocytopenia among survivors almost always resulted in recovery from thrombocytopenia.