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Critical Care and Anaesthesia
Published in Tjun Tang, Elizabeth O'Riordan, Stewart Walsh, Cracking the Intercollegiate General Surgery FRCS Viva, 2020
Rajkumar Rajendram, Alex Joseph, John Davidson, Avinash Gobindram, Prit Anand Singh, Animesh JK Patel
How do you treat DIC?Treat the underlying disorder.Platelets and FFP to replenish consumed factors: Only if the patient is bleeding or there is a risk of bleeding.<50 × 109/L in the presence of bleeding, and if <10 × 109/L without bleeding.Anti-fibrinolytic therapy should be considered if bleeding persists.Cryoprecipitate and fibrinogen possibly needed in high-risk patients.Packed red cells may also be required if the haemolytic anaemia is severe.Early haematology advice and support is recommended.
Current status of fibrinolytic therapy
Published in K Sarat Chandra, AJ Swamy, Acute Coronary Syndromes, 2020
Saubhik Kanjilal, Soumitra Kumar
ST-elevated myocardial infarction remains one of the major public health problems, the incidence of which is on the rise all over the world, especially in developing countries, despite advancement in the diagnosis and management. Over the years, the primary mode of care of STEMI patients has changed from a primary pharmacologic strategy to a catheter-based one. Progressive loss of myocyte after a STEMI is linearly related to the duration of occlusion of infarct related artery. Hence, the goal of therapy of such patients is to do reperfusion of the occluded artery at the earliest. For most patients of STEMI, primary PCI is the preferred option. RCTs have shown that if time delay is similar, then primary PCI is superior to fibrinolysis in reducing mortality, reinfarction and stroke [1–5]. Fibrinolytic therapy is to be offered in a timely manner (in absence of any contraindications) to all patients who do not have the option of primary PCI, especially if they present early in their window period. As the time of presentation increases, the efficacy and clinical benefit of fibrinolytic therapy decreases [7]. It can prevent 30 deaths out of 1000 patients treated within 6 hours of onset of AMI [6]. Such pharmacologic therapy is capable of establishing antegrade flow in 75% of cases. However, there is 30% chance of re-occlusion after fibrinolysis alone.
Thromboembolic Events in Prosthetic Valves
Published in Hau C. Kwaan, Meyer M. Samama, Clinical Thrombosis, 2019
J. Acar, P. L. Michel, J. Berdah
What are respective indications of fibrinolytic therapy and surgery? That is a controversial question concerning patients with occlusive thrombosis of prosthesis. Surgery is usually preferred when the operative risk does not appear as too high. It is the case in young patients with a good myocardial function and gradual clinical manifestations over several days; on the other hand, fibrinolytic treatment is preferred in very critically ill patients who are too sick to undergo immediate surgery. It is often the case of a patient with bad myocardial function and multiple valve replacement.
Pleural infection: a closer look at the etiopathogenesis, microbiology and role of antibiotics
Published in Expert Review of Respiratory Medicine, 2019
Eihab O. Bedawi, Maged Hassan, David McCracken, Najib M. Rahman
Pleural infection is an important condition that requires urgent attention, independent of pneumonia. Recent advances continue to unravel new areas of knowledge relating to the pathogenesis, involving the host, the bacteria and the pleural environment. These are vital to future advances in treatment. The microbiology is variable, evidently evolving and has been demonstrated to influence outcomes in patients, suffering from this condition. Delays in diagnosis, unacceptably low culture yields and polymicrobial infections are likely to be ongoing challenges. Further validation of pleural biopsy in larger cohorts is an exciting development and may even extend the spectrum of organisms known to be involved. For now, our knowledge of antibiotic penetration is limited mainly to rabbit models of empyema. The increased incidence in the elderly, with limitations of surgery in this group, means that advances in intrapleural fibrinolytic therapy are going to be key in improving outcomes.
Investigational drugs for the treatment of acute myocardial infarction: focus on antiplatelet and anticoagulant agents
Published in Expert Opinion on Investigational Drugs, 2019
Srikanth Yandrapalli, Gabriela Andries, Shashvat Gupta, Abdel Rahman Dajani, Wilbert S. Aronow
Ximelagatran is an oral direct thrombin inhibitor and the first novel oral anticoagulant that has been studied for prevention of thromboembolic events post ACS [66]. In the ESTEEM (Efficacy and Safety of The Oral Direct Thrombin Inhibitor Ximelagatran in Patients with Recent Myocardial Damage) trial, patients with ACS (within 14 days of initial event) were randomized to receive one of four doses of oral ximelagatran (24 mg BID, 36 mg BID, 48 mg BID, or 60 mg BID) versus placebo [67]. Primary outcome was the occurrence of the composite clinical endpoint of all-cause death, non-fatal AMI, and severe recurrent ischemia. The investigators found that the combination of ximelagatran and aspirin significantly reduced the primary endpoint compared with aspirin alone. However, the frequency of major and minor bleeding events and elevation of liver enzymes were higher in the ximelagatran group. The design of this trial did not reflect current recommended practice: patients receiving other antiplatelet agents (aside from aspirin), having had PCI in the past 4 months, or planned to have PCI within 60 days were excluded. Fifty percent of patients in the trial were treated with fibrinolytic therapy [67]. Currently, ximelagatran has been removed from market primarily because of safety reasons related to the drug’s adverse effects on liver function [68].
Making a case for the right ‘-ase’ in acute ischemic stroke: alteplase, tenecteplase, and reteplase
Published in Expert Opinion on Drug Safety, 2019
Katleen Wyatt Chester, Megan Corrigan, J. Megan Schoeffler, Michelle Shah, Florence Toy, Barbara Purdon, George M. Dillon
The landscape of fibrinolytic therapy for AIS is becoming increasingly complex as new clinical uses and dosing strategies are evaluated in the AIS population, several of which have led to the potential for practice changes. For example, within the confines of strict clinical and imaging parameters, wake-up strokes may be considered for treatment with alteplase [11], whereas mild ischemic strokes can be considered for treatment with tenecteplase instead of alteplase [5,12]. As the use of fibrinolytic therapy grows, so too does the risk of medication errors. Providers who practice in settings where fibrinolytic therapy may be used must have a working knowledge of the fibrinolytic agents, including their indications, specific criteria for use, contraindications, dosing, administration, and medication error prevention strategies.