Use of four-factor prothrombin complex concentrate (4F-PCC) for management of bleeding not associated with therapeutic anticoagulant use

INTRODUCTION

Four-factor prothrombin complex concentrate (4F-PCC) may be an option for patients with bleeding unrelated to therapeutic anticoagulation to help with bleeding cessation and reduce blood component requirements.

MATERIALS AND METHODS

Retrospective, observational study of adult patients who received 4F-PCC for bleeding not associated with therapeutic anticoagulation between June 2019 and July 2021. Primary outcome was to describe off-label 4F-PCC use in patients not on therapeutic anticoagulation for bleeding management in surgical and non-surgical patients. Additional outcomes evaluated were blood product use, chest tube and drainage output, and coagulation studies before and after 4F-PCC administration as well as other hemostatic agent use and thromboembolic events.

RESULTS

Seventy-six patients were included; median age 64 years (IQR 50-69), 66% of bleeding events were associated with surgery, and the majority of 4F-PCC doses ordered by cardiac surgery (68.4%). A total of 110 4F-PCC doses were administered; median 1 dose/patient (IQR 1-2), median total dose 1000 units (IQR 500-1484). Other hemostatic agents commonly administered were protamine (59%), desmopressin (43%), and tranexamic acid (42%). Packed red blood cells, fresh frozen plasma, platelet, and cell saver blood administration and prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (aPTT) were significantly reduced following 4F-PCC administration. Eight patients (11%) experienced thromboembolic complications.

CONCLUSION

Relatively low doses of 4F-PCC (median total dose 1000 units) were associated with decreased blood component requirements and improved PT, INR, and aPTT values in patients with bleeding unrelated to therapeutic anticoagulation. Other hemostatic agent use was common and thromboembolic complications occurred.

Negative Outcome Following Systemic Alteplase Administration Prior to Extracorporeal Membrane Oxygenation in a Kidney Transplant Patient With Cardiac Arrest: A Case Report

A case of a negative outcome following systemic alteplase administration prior to extracorporeal membrane oxygenation (ECMO) in a kidney transplant patient with cardiac arrest is reported. A patient status-post kidney transplantation was admitted to the surgical intensive care unit (ICU) and experienced cardiac arrest after developing sudden-onset chest pain and shortness of breath. During cardiopulmonary resuscitation, alteplase 50 mg was administered intravenous push for suspected pulmonary embolism (PE) before the patient was evaluated for and started on veno-arterial ECMO. Within several hours, cardiopulmonary resuscitation needed to be reinitiated. Ultimately, the decision was made to cede further resuscitation efforts due to futility. A post-mortem examination included an immediate cause of death of acute myocardial infarction with extensive retroperitoneal hemorrhage. The role of ECMO is emerging in cardiac arrest, and should be considered as a management option before the administration of systemic thrombolysis in patients with increased bleeding risk.

Enhanced Recovery After Surgery in Patients Implanted with Left Ventricular Assist Device

INTRODUCTION

We sought to develop and implement a comprehensive enhanced recovery after surgery (ERAS) protocol for patients implanted with a left ventricular assist device (LVAD).

METHODS AND RESULTS

In this article, we describe our approach to the development and phased implementation of the protocol. Additionally, we reviewed prospectively collected data for patients who underwent LVAD implantation at our institution from February 2019 to August 2020. To compare early outcomes in our patients before and after protocol implementation, we dichotomized patients into two 6-month cohorts (the pre-ERAS and ERAS cohorts) separated from each other by 6 months to allow for staff adoption of the protocol. Of the 115 LVAD implants, 38 patients were implanted in the pre-ERAS period and 46 patients in the ERAS period. Preoperatively, the patients` characteristics were similar between the cohorts. Postoperatively, we observed a decrease in bleeding (chest tube output of 1006 vs 647.5 mL, P < .001) and blood transfusions (fresh frozen plasma 31.6% vs 6.7%, P = .04; platelets 42.1% vs 8.7%, P = .001). Opioid prescription at discharge were 5-fold lower with the ERAS approach (P < .01). Furthermore, the number of patients discharged to a rehabilitation facility decreased significantly (20.0% vs 2.4%, P = .02). The index hospitalization length of stay and survival were similar between the groups.

CONCLUSIONS

ERAS for patients undergoing LVAD implantation is a novel, evidence-based, interdisciplinary approach to care with multiple potential benefits. In this article, we describe the details of the protocol and early positive changes in clinical outcomes. Further studies are needed to evaluate benefits of an ERAS protocol in an LVAD population.Lay Summary: Enhanced recovery after surgery (ERAS) is the implementation of standardized clinical pathways that ensures the use of best practices and decreased variation in perioperative care. Multidisciplinary teams work together on ERAS, thereby enhancing communication among health care silos. ERAS has been used for more than 30 years by other surgical services and has been shown to lead to a decreased length of stay, fewer complications, lower mortality, fewer readmissions, greater job satisfaction, and lower costs. Our goal was to translate these benefits to the perioperative care of complex patients with a left ventricular assist device. Early results suggest that this goal is possible; we have observed a decrease in transfusions, discharge on opioids, and discharge to a rehabilitation facility.

The use of hydroxocobalamin for vasoplegic syndrome in left ventricular assist device patients

We demonstrate evidence supporting the efficacy of hydroxocobalamin in reducing vasopressor requirements for LVAD patients with refractory vasoplegia. Further study is needed to substantiate these findings and determine its optimal use in practice.

Mortality in ulcerative colitis-what should we tell our patients? Three year mortality following admission for the treatment of ulcerative colitis: a 6 year retrospective case review

OBJECTIVES

To determine the 3 year mortality of patients admitted to hospital for the treatment of ulcerative colitis (UC).

DESIGN

Retrospective case note review of all patients admitted to hospital for treatment of active UC over a 6 year period from 1 January 2000.

SETTING

Teaching hospital with a tertiary referral practice for the management of infiammatory bowel disease.

PATIENTS

106 patients (134 admissions) met the inclusion criteria.

INTERVENTIONS

Elective and emergency colectomy was undertaken in 16 and 26 patients, respectively.

MAIN OUTCOME MEASURES

Mortality at 3 years.

RESULTS

There were six deaths after 3 years. Case fatality at 30 days, 1, 2 and 3 years was 1.0% (95% CI 0.2 to 5.1), 1.9% (95% CI 0.2 to 6.6), 2.9% (95% CI 5.9 to 8.0) and 5.7% (95% CI 2.1 to 11.9), respectively. There were no deaths in either surgical group. One patient (89 years, female) died while awaiting emergency colectomy. Patients who died were significantly older at the time of admission (79 years (95% CI 71 to 88 years) vs 41.2 years (95% CI 38 to 45 years)) and were more likely to have comorbid illness (p<0.001). Severity of disease, prior immunosuppressive use, first presentation and smoking status were not associated with increased mortality.

CONCLUSIONS

Three year mortality following admission for treatment of UC was 5.7% (95% CI 2.1 to 11.9), significantly lower than that reported previously. Mortality was significantly associated with increasing age and the presence of comorbid disease. Disease specific factors such as severity, extent and first presentation were associated with emergency colectomy but not mortality.

Male Afro-Caribbean patients admitted to Rampton Hospital between 1977 and 1986--a control study

All Afro-Caribbean patients admitted to the Mental Illness Division of Rampton Hospital (a Special Hospital) between 1977 and 1986 and a randomly selected control cohort of Non Afro-Caribbean patients admitted in the same period, were compared on a variety of sociodemographic, psychiatric, criminological, treatment and outcome variables. Significantly, fewer of the Afro-Caribbean patients attracted the legal classification of Psychopathic Disorder. Detailed analysis was thus restricted to mentally ill patients in the two ethnic groupings. Similarities outweighed differences. There was no difference between the groups in terms of index offence, previous custodial sentence, in-patient psychiatric admission (including previous Special Hospital admission), admission source, Mental Health Act section, length of admission (including readmission) to Special Hospitals, likelihood of discharge or place to which discharged. Medication history in Special Hospitals was similar at one year and three years after admission. Afro-Caribbean patients had a lower incidence of childhood institutional care, a decreased likelihood of a previous supervision order, an increased likelihood of a previous Court appearance and received higher doses of antipsychotic medication four weeks after admission to Special Hospital.

Electroconvulsive therapy and cognitive improvement in a very elderly depressed patient

A computer search of the literature revealed that the oldest documented patient to receive electro convulsive therapy (ECT) was a 94-year-old woman (Bernstein, 1972) who was diagnosed as having ‘anorexniearvosa’, but the history was suggestive of paranoid schizophrenia. She received a course of five ECTs and became much less paranoid, ate well, and put on weight. Her daughter lamented the fact that ECT had been deemed to be contra indicated 15years earlier on the grounds of advanced age.

Aspects of deliberate self-harm

Research into suicide and attempted suicide (parasuicide, non-fatal deliberate self-harm) has led to a vast accumulation of literature at a rate too fast to permit the generalist easily to keep himself informed of the latest thinking in these emotive and tragic areas. What are the latest facts in this often overpowering mass of data and speculative thinking? This article offers a guide to modern suicidology.