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Martens KL, Dekker SE, Crowe M, DeLoughery TG, Shatzel JJ. Challenging clinical scenarios for therapeutic anticoagulation: A practical approach. Thromb Res 2022; 218:72-82. [PMID: 36027629 PMCID: PMC9481720 DOI: 10.1016/j.thromres.2022.08.015] [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: 04/27/2022] [Revised: 07/20/2022] [Accepted: 08/15/2022] [Indexed: 01/03/2023]
Abstract
Therapeutic anticoagulation remains a fundamental backbone in the treatment and prevention of venous thromboembolism. However, while modern therapies are increasingly safe, anticoagulation is not without risks, particularly in those at high risk for or with recent bleeding. When weighing concurrent risks and benefits in each challenging clinical scenario, an individualized assessment of the risk and acuity of bleeding should be balanced by the indication for anticoagulation. Addressing modifiable risk factors and routine re-evaluation of any changes in this balance is critical. This review outlines available data and current guidelines for the management of anticoagulation in high-risk populations, including those with thrombocytopenia, elderly and high-fall risk, inherited bleeding disorders, and in acute coronary syndrome. We also examine management after clinically significant bleeding episodes, including intracranial hemorrhage, gastrointestinal bleeding, hemoptysis, retroperitoneal bleeding, hematuria, and abnormal uterine bleeding. The aim is to provide a comprehensive review of available literature to guide clinicians in providing optimal, safe, and individualized care for patients in these challenging scenarios.
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Affiliation(s)
- Kylee L. Martens
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, United States of America,Corresponding author at: OHSU Knight Cancer Institute, 3181 SW Sam Jackson Park Road, Mail Code: OC14HO, Portland, OR 97239, United States of America. (K.L. Martens)
| | - Simone E. Dekker
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Megan Crowe
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Thomas G. DeLoughery
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, United States of America
| | - Joseph J. Shatzel
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, United States of America
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Khaja M, Haider A, Alapati A, Qureshi ZA, Yapor L. Percutaneous Tracheostomy: A Bedside Procedure. Cureus 2022; 14:e24083. [PMID: 35573523 PMCID: PMC9098100 DOI: 10.7759/cureus.24083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 11/23/2022] Open
Abstract
Percutaneous tracheostomy is a bedside surgical procedure that creates an opening in the anterior tracheal wall. Tracheostomy is performed in patients expected to require mechanical ventilation for longer than seven to 10 days. This bedside percutaneous tracheostomy has been used since the late 1990s. Tracheotomy tubes are of various kinds like cuffed vs. uncuffed, fenestrated vs. unfenestrated, single lumen vs. double lumen, and metal vs. plastic. Its indications are categorized into emergency vs. elective. The most common emergency indication is acute airway obstruction, and the elective indication is prolonged intubation. There is no absolute contraindication, but a physician should consider severe hypoxia requiring high oxygen and coagulopathy. Percutaneous tracheostomy is a new technique requiring different skills. Advantages of percutaneous tracheostomy are as follows - it is performed at the bedside, procedural time is less, the cost is less, does not need operating schedule time. Percutaneous tracheostomy is generally performed by otolaryngologists, general surgeons, interventional pulmonologists, thoracic surgeons, or intensivists.
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Affiliation(s)
- Misbahuddin Khaja
- Internal Medicine/Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai/Bronx Care Health System, New York City, USA
| | - Asim Haider
- Internal Medicine, Icahn School of Medicine at Mount Sinai/Bronx Care Health System, New York City, USA
| | - Anuhya Alapati
- Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai/Bronx Care Health System, New York City, USA
| | - Zaheer A Qureshi
- Internal Medicine, Icahn School of Medicine at Mount Sinai/Bronx Care Health System, New York City, USA
| | - Laura Yapor
- Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai/Bronx Care Health System, New York City, USA
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Abstract
PURPOSE OF REVIEW As the prevalence of patients on antithrombotics is increasing, anesthesiologists must have a firm understanding of these medications and considerations for their periprocedural management. This review details up-to-date periprocedural management of direct oral anticoagulants (DOACs). RECENT FINDINGS DOACs have favorable pharmacokinetics including quick onset of action and short half-lives. Periprocedural management of DOACs relies heavily on drug half-life as well as procedural risk of bleeding. Other than a few exceptions, the American College of Cardiologists generally recommends complete clearance of oral anticoagulants prior to high-risk bleeding procedures and partial clearance prior to low-risk bleeding procedures. Procedures with little to no clinical risk of bleeding can be performed without any drug interruption or during trough levels. Exceptions to periprocedural DOAC management pertain to electrophysiology procedures. SUMMARY With the exception of no clinically relevant bleeding risk or certain electrophysiology procedures, DOACs should be discontinued periprocedurally in accordance with bleeding risks and drug's half-life. Bridging is generally not recommended for DOACs.
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Shaller BD, Gildea TR. What is the value of electromagnetic navigation in lung cancer and to what extent does it require improvement? Expert Rev Respir Med 2020; 14:655-669. [DOI: 10.1080/17476348.2020.1748012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Brian D. Shaller
- Interventional Pulmonology, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas R. Gildea
- Interventional Pulmonology, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Delayed Presentation of Hemothorax and Mediastinal Hematoma Requiring Surgical Intervention After Linear Endobronchial Ultrasound. J Bronchology Interv Pulmonol 2020; 26:e50-e52. [PMID: 31569102 DOI: 10.1097/lbr.0000000000000589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Barnes H, Gurry G, McGiffin D, Westall G, Levin K, Paraskeva M, Whitford H, Williams T, Snell G. Atrial Flutter and Fibrillation Following Lung Transplantation: Incidence, Associations and a Suggested Therapeutic Algorithm. Heart Lung Circ 2019; 29:1484-1492. [PMID: 31786113 DOI: 10.1016/j.hlc.2019.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/25/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Atrial arrhythmias are relatively common following lung transplantation and confer considerable perioperative risk, specifically haemodynamic instability, pulmonary congestion, dyspnoea, and can mask other post-transplant complications such as infection or acute rejection. However, for most patients, arrhythmias are limited to the short-term perioperative period. METHODS We present a retrospective case-control analysis of 200 lung transplant recipients and using multivariate regression analysis, document the present incidence, risk factors, and outcomes between the two groups. RESULTS Twenty-five per cent (25%) of lung transplantation patients developed atrial flutter or fibrillation, most frequently at day 5-7 post lung transplantation, and more commonly present in older recipients and those with underlying chronic obstructive pulmonary disease (COPD), but not in those with previously noted structural heart disease, or in those undergoing single rather than double lung transplants. Atrial arrhythmias were associated with increased intensive care unit and overall length of stay, but were not associated with increased risk of in-hospital stroke, or mortality. Based on our experience, we propose a suggested management algorithm for pharmacological and mechanical rate/rhythm control strategies, for anticoagulation, and discuss the appropriate duration of treatment. CONCLUSIONS Atrial arrhythmias are relatively common post lung transplantation. Carefully managed, the associated risk of perioperative morbidity and mortality can be mitigated. Further prospective studies are required to validate these strategies.
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Affiliation(s)
- Hayley Barnes
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Vic, Australia.
| | - Greta Gurry
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - David McGiffin
- Department of Cardiothoracic Surgery and Transplantation Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Glen Westall
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Kovi Levin
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Miranda Paraskeva
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Helen Whitford
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Trevor Williams
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Greg Snell
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
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Simon RP, Oromendia C, Sanso LM, Ramos LG, Rajwani K. Bronchoscopic delivery of aminocaproic acid as a treatment for pulmonary bleeding: A case series. Pulm Pharmacol Ther 2019; 60:101871. [PMID: 31783097 DOI: 10.1016/j.pupt.2019.101871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/21/2019] [Accepted: 11/25/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Bronchoscopy is an essential therapeutic modality in the treatment of pulmonary bleeding. Although numerous endoscopic treatments exist, topical ε-aminocaproic acid has not been described in the literature. This study documents the use of this novel treatment for pulmonary bleeding and compares it to available evidence for tranexamic acid, a similar anti-fibrinolytic agent. DESIGN Case-series study. SETTING ICU and general inpatient floors of a tertiary medical center. PATIENTS Forty-six patients receiving endobronchial ε-aminocaproic acid for the treatment or prevention of pulmonary bleeding. MEASUREMENTS AND MAIN RESULTS Of the 46 patients included in the study, 41.6% and 13% presented with non-massive and massive hemoptysis, respectively. In patients with active pulmonary bleeding, endobronchial application of ε-aminocaproic acid and accompanying therapies resulted in cessation of bleeding in 94.7% of cases. A total of six patients received ε-aminocaproic acid monotherapy; in three patients with active bleeding, 100% achieved hemostasis after treatment. Of the 36 patients successfully treated for active pulmonary bleeding, 27.8% had recurrent bleeding within 30 days. Thirty-day adverse events were as follows: death (10 patients), deep vein thrombosis (2 patients), renal failure (2 patients), and stroke (2 patients). CONCLUSIONS Endobronchial administration of ε-aminocaproic acid during bronchoscopy may be a safe and efficacious option in the treatment and prevention of pulmonary bleeding. Further studies are necessary to better define ε-aminocaproic acid's safety profile, optimal routes of administration, and comparative effectiveness to tranexamic acid.
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Affiliation(s)
- Russell P Simon
- Department of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Clara Oromendia
- Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA
| | - Lourdes M Sanso
- Department of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Liz G Ramos
- Department of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Kapil Rajwani
- Department of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
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Tao J, Oprea AD. Periprocedural Anticoagulation Management For Nonoperating Room Anesthesia Procedures: A Clinical Guide. Semin Cardiothorac Vasc Anesth 2019; 23:352-368. [PMID: 31431127 DOI: 10.1177/1089253219870627] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Non-operating room anesthesia presents unique challenges for anesthesiologists. Limited preprocedural optimization and unfamiliarity with the location and procedure itself add to the difficulties in delivering safe care for these patients. Management of chronic oral anticoagulation can prove especially problematic since risks of bleeding for non-operating room procedures vary widely and differ from traditional surgeries. In addition, many physicians may not be familiar with the growing number of newly approved oral anticoagulants and their periprocedural management. This review will examine common non-operating procedures, their risks of bleeding, as well as pharmacokinetics of oral anticoagulants available on the market and periprocedural management options.
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Affiliation(s)
- Jing Tao
- Yale University, New Haven, CT, USA
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Uddin LN, Egorov AV, Sokolova AA, Morozova NS, Napalkov DA, Fomin VV. Features of Thromboembolic and Hemorrhagic Complications in Planned Surgical Interventions in Patients with Atrial Fibrillation. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2019. [DOI: 10.20996/1819-6446-2019-15-3-315-321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim. To study the frequency and characteristics of the development of thromboembolic and hemorrhagic complications in patients with atrial fibrillation (AF) during planned surgical interventions.Material and methods. Preoperative examination and postoperative observation of 214 patients with AF (139 men and 75 women) who received anticoagulant therapy (ACT) and underwent planned surgery was carried out. The consistency of the used perioperative ACT regimens when performing interventions with current international recommendations was analyzed.Results. Complications developed in 33 patients (15.4%) from the total sample of 214 patients: in 14 (6.5%) thromboembolism, in 19 (8.9%) hemorrhagic complications. Analysis of the complication frequency in various types of surgical interventions showed that the frequency of thromboembolism during heart and vascular operations was 9.8% (4 cases), with interventions for malignant tumors – 7 (6.2%), while performing general surgical abdominal tumors operations – 3 (5.0%). The frequency of bleeding was maximum during operations for cancer 18.6%, this value was significantly higher compared with the frequency of these complications when performing general surgical abdominal operations – 3 cases (5.0%), and during interventions on the heart and vascular vessels bleedings were not observed. The total frequency of complications was also maximal when performing interventions for malignant tumors – 24.8%. This value was significantly higher than in the groups of patients who underwent general surgical abdominal operations – 10.0%, and interventions on the heart and vessels – 9.8%. Analysis of the frequency of compliance with the recommendations of the European Society of Cardiology in terms of ACT usage in patients with AF in the perioperative period and the structure of errors in choosing the ACT regimen showed that among the examined patients the recommendations were followed only in 102 (47.7%), while the frequency of non-recommended regimens use reached 52.3% (112 patients). The most frequently incorrectly used scheme was “bridge therapy” with the possibility of canceling oral anticoagulants in 107 (50.0%) patients.Conclusion. A significantly higher frequency of complications was found in patients, whose management did not follow the recommendations for perioperative ACT.
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Affiliation(s)
- L. N. Uddin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. V. Egorov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. A. Sokolova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - N. S. Morozova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - D. A. Napalkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - V. V. Fomin
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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Management of Antiplatelet Agents in Peribronchoscopic Period: How Soon is Safe Enough? J Bronchology Interv Pulmonol 2019; 26:e30-e31. [PMID: 31233472 DOI: 10.1097/lbr.0000000000000569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Calnan MW, Crawford AN. A Case Report of Cangrelor Bridge Therapy for a Diagnostic Bronchoscopy With Biopsy. J Pharm Pract 2018; 33:231-235. [PMID: 30139291 DOI: 10.1177/0897190018795343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Although premature discontinuation of dual antiplatelet therapy (DAPT) is associated with an increased risk of ischemic complications, patients may present with an urgent need for surgery that would require interruption of DAPT. Antiplatelet bridge therapy using cangrelor, an intravenous P2Y12 inhibitor, has been studied as a potential option to ensure continuation of DAPT perioperatively. However, limited evidence exists supporting the off-label use of cangrelor bridge therapy to noncardiac procedures. We describe the case of a 67-year-old class 3 obese female on DAPT (aspirin and ticagrelor) for recent drug-eluting stent placement who required a bronchoscopy with biopsy for suspected lung cancer. Cangrelor bridge therapy was utilized both preoperatively and postoperatively without ischemic or bleeding complications, and the patient was subsequently able to begin radiation therapy after a confirmed diagnosis of lung cancer.
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Affiliation(s)
- Matthew W Calnan
- Department of Pharmacy, Bon Secours Memorial Regional Medical Center, Mechanicsville, VA, USA
| | - Alexis N Crawford
- Department of Pharmacy, Bon Secours Memorial Regional Medical Center, Mechanicsville, VA, USA
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Ergan B, Nava S. The use of bronchoscopy in critically ill patients: considerations and complications. Expert Rev Respir Med 2018; 12:651-663. [PMID: 29958019 DOI: 10.1080/17476348.2018.1494576] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Flexible bronchoscopy has been well established for diagnostic and therapeutic purposes in critically ill patients. Areas covered: This review outlines the clinical evidence of the utility and safety of flexible bronchoscopy in the intensive care unit, as well as specific considerations, including practical points and potential complications, in critically ill patients. Expert commentary: Its ease to learn and perform and its capacity for bedside application with relatively few complications make flexible bronchoscopy an indispensable tool in the intensive care unit setting. The main indications for flexible bronchoscopy in the intensive care unit are the visualization of the airways, sampling for diagnostic purposes and management of the artificial airways. The decision to perform flexible bronchoscopy can only be made by trade-offs between potential risks and benefits because of the fragile nature of the critically ill. Flexible bronchoscopy-associated serious adverse events are inevitable in cases of a lack of expertise or appropriate precautions.
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Affiliation(s)
- Begum Ergan
- a Department of Pulmonary and Critical Care , School of Medicine, Dokuz Eylul University , Izmir , Turkey
| | - Stefano Nava
- b Department of Clinical , Integrated and Experimental Medicine (DIMES), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Alma Mater University , Bologna , Italy
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