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Prior A, Fiaschi P, Iaccarino C, Stefini R, Battaglini D, Balestrino A, Anania P, Prior E, Zona G. How do you manage ANTICOagulant therapy in neurosurgery? The ANTICO survey of the Italian Society of Neurosurgery (SINCH). BMC Neurol 2021; 21:98. [PMID: 33658003 PMCID: PMC7927258 DOI: 10.1186/s12883-021-02126-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 02/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anticoagulant assumption is a concern in neurosurgical patient that implies a delicate balance between the risk of thromboembolism versus the risk of peri- and postoperative hemorrhage. METHODS We performed a survey among 129 different neurosurgical departments in Italy to evaluate practice patterns regarding the management of neurosurgical patients taking anticoagulant drugs. Furthermore, we reviewed the available literature, with the aim of providing a comprehensive but practical summary of current recommendations. RESULTS Our survey revealed that there is a lack of knowledge, mostly regarding the indication and the strategies of anticoagulant reversal in neurosurgical clinical practice. This may be due a lack of national and international guidelines for the care of anticoagulated neurosurgical patients, along with the fact that coagulation and hemostasis are not simple topics for a neurosurgeon. CONCLUSIONS To overcome this issue, establishment of hospital-wide policy concerning management of anticoagulated patients and developed in an interdisciplinary manner are strongly recommended.
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Affiliation(s)
- Alessandro Prior
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pietro Fiaschi
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
- Università di Genova, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 1016132, Genoa, Italy.
| | | | - Roberto Stefini
- Department of Neurosurgery, Ospedale Civile di Legnano, Milan, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Alberto Balestrino
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pasquale Anania
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Enrico Prior
- Division of Cardiology, Department of Medicine University of Verona, Verona, Italy
| | - Gianluigi Zona
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Università di Genova, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 1016132, Genoa, Italy
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Roberts SJ, Pokrandt P, Jewell E, Engoren M, Berg MP, Maile MD. Association of four-factor prothrombin complex concentrate with subsequent plasma transfusion: A retrospective cohort study. Transfus Med 2020; 31:69-75. [PMID: 32981200 DOI: 10.1111/tme.12716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 02/22/2020] [Accepted: 09/07/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess whether patients prescribed four-factor prothrombin complex concentrate (4FPC) received less plasma during the following 24-hour period than those treated for the same indications who received only plasma. INTRODUCTION It is unclear whether 4FPC is associated with a reduction in subsequent plasma transfusion. This is important for minimising transfusion-associated risks and for inventory management. MATERIALS AND METHODS We retrospectively studied patients treated for bleeding or coagulopathy. Individuals receiving 4FPC were matched by indication to patients treated with only plasma. Blood products received during 24-hour follow up were compared between 4FPC and plasma-only patients. RESULTS There was no difference in the number of patients receiving additional plasma (19 (21%) 4FPC patients vs 31 (34%) plasma-only patients, P = .07) nor in the median number of additional plasma units received (0 units for both groups, interquartile range [0, 0] for 4FPC patients vs [0, 1] for plasma-only patients, P = .09). Subgroup analysis comparing patients who received 4FPC for on-label vs off-label indications found no difference in the number of patients receiving plasma nor in the median number of plasma units received. CONCLUSION 4FPC was prescribed to a diverse set of patients, and administration was not associated with reduced plasma transfusion at our institution.
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Affiliation(s)
- Sammie J Roberts
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Paul Pokrandt
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth Jewell
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Milo Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Mary P Berg
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael D Maile
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
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Doctor J, MacEwan JP. Limitations of traditional health technology assessment methods and implications for the evaluation of novel therapies. Curr Med Res Opin 2017; 33:1635-1642. [PMID: 28756684 DOI: 10.1080/03007995.2017.1359151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Jason Doctor
- a Schaeffer Center for Health Policy and Economics , University of Southern California , Los Angeles , CA , USA
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Abstract
Transfusion of various blood components can provide relief from symptomatic anemia and reduce the bleeding risks associated with low platelet counts or presence of coagulopathy. Blood components are collected from volunteer donors and processed into separate components to maximize efficient utilization of a scarce resource while also providing maximum clinical benefit. Tests including blood type and screening for clinically significant alloantibodies increase the likelihood of successful transfusion. Risks of transfusion include hypersensitivity and hemolytic transfusion reactions, transfusion-related acute lung injury, transfusion-associated circulatory overload, and transmission of infection. Indications for transfusion are reviewed along with various products available for transfusion.
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Affiliation(s)
- Nathan T Connell
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Steiner T, Poli S, Griebe M, Hüsing J, Hajda J, Freiberger A, Bendszus M, Bösel J, Christensen H, Dohmen C, Hennerici M, Kollmer J, Stetefeld H, Wartenberg KE, Weimar C, Hacke W, Veltkamp R. Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial. Lancet Neurol 2016; 15:566-73. [PMID: 27302126 DOI: 10.1016/s1474-4422(16)00110-1] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 02/15/2016] [Accepted: 03/02/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Haematoma expansion is a major cause of mortality in intracranial haemorrhage related to vitamin K antagonists (VKA-ICH). Normalisation of the international normalised ratio (INR) is recommended, but optimum haemostatic management is controversial. We assessed the safety and efficacy of fresh frozen plasma (FFP) versus prothrombin complex concentrate (PCC) in patients with VKA-ICH. METHODS We did an investigator-initiated, multicentre, prospective, randomised, open-label, blinded-endpoint trial. Patients aged at least 18 years with VKA-ICH who presented within 12 h after symptom onset with an INR of at least 2·0 were randomly assigned (1:1) by numbered sealed envelopes to 20 mL/kg of intravenous FFP or 30 IU/kg of intravenous four-factor PCC within 1 h after initial cerebral CT scan. The primary endpoint was the proportion of patients with INR 1·2 or lower within 3 h of treatment initiation. Masking of treatment was not possible, but the primary analysis was observer masked. Analyses were done using a treated-as-randomised approach. This trial is registered with EudraCT, number 2008-005653-37, and ClinicalTrials.gov, number NCT00928915. FINDINGS Between Aug 7, 2009, and Jan 9, 2015, 54 patients were randomly assigned (26 to FFP and 28 to PCC) and 50 received study drug (23 FFP and 27 PCC). The trial was terminated on Feb 6, 2015, after inclusion of 50 patients after a safety analysis because of safety concerns. Two (9%) of 23 patients in the FFP group versus 18 (67%) of 27 in the PCC group reached the primary endpoint (adjusted odds ratio 30·6, 95% CI 4·7-197·9; p=0·0003). 13 patients died: eight (35%) of 23 in the FFP group (five from haematoma expansion, all occurring within 48 h after symptom onset) and five (19%) of 27 in the PCC group (none from haematoma expansion), the first of which occurred on day 5 after start of treatment. Three thromboembolic events occurred within 3 days (one in the FFP group and two in the PCC group), and six after day 12 (one and five). 43 serious adverse events (20 in the FFP group and 23 in the PCC group) occurred in 26 patients. Six serious adverse events were judged to be FFP related (four cases of haematoma expansion, one anaphylactic reaction, and one ischaemic stroke) and two PCC related (ischaemic stroke and pulmonary embolism). INTERPRETATION In patients with VKA-related intracranial hemorrhage, four-factor PCC might be superior to FFP with respect to normalising the INR, and faster INR normalisation seemed to be associated with smaller haematoma expansion. Although an effect of PCC on clinical outcomes remains to be shown, our data favour the use of PCC over FFP in intracranial haemorrhage related to VKA. FUNDING Octapharma.
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Affiliation(s)
- Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany; Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.
| | - Sven Poli
- Department of Neurology and Stroke, Hertie Institute for Clinical Brain Research, Tübingen University Hospital, Germany
| | - Martin Griebe
- Department of Neurology, Mannheim UMM, Heidelberg University, Heidelberg, Germany
| | - Johannes Hüsing
- Coordination Center for Clinical Trials, Heidelberg University Hospital, Heidelberg, Germany
| | - Jacek Hajda
- Coordination Center for Clinical Trials, Heidelberg University Hospital, Heidelberg, Germany
| | - Anja Freiberger
- Coordination Center for Clinical Trials, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hanne Christensen
- Department of Neurology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark
| | - Christian Dohmen
- Department of Neurology, Cologne University Hospital, Cologne, Germany
| | - Michael Hennerici
- Department of Neurology, Mannheim UMM, Heidelberg University, Heidelberg, Germany
| | - Jennifer Kollmer
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Henning Stetefeld
- Department of Neurology, Cologne University Hospital, Cologne, Germany
| | | | - Christian Weimar
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Werner Hacke
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Roland Veltkamp
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany; Department of Stroke Medicine, Imperial College London, London, UK
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