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Coagulopathy
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
The mainstays of treatment for coagulopathies continues to be treatment of the underlying condition, replacement of deficiencies and discontinuation of any anti-thrombotic or anti-platelet medications. Guidelines for platelet transfusion vary depending on the clinical scenario; however, most guidelines support transfusion for a platelet count of <30–50 × 109/L in high risk patients and for <10 × 109/L in all patients [2, 8]. Plasma may be necessary when repletion of multiple coagulation factors is needed, especially during massive hemorrhage, although prothrombin complex concentrates (PCCs), isolated recombinant coagulation factors, and newer specific reversal agents may be more favorable depending on the clinical context. PCCs contain all vitamin K dependent factors (II, VII, IX, X) and should be considered for immediate reversal of a vitamin K antagonist for life-threatening bleeding, especially if a large volume transfusion would not be tolerated. In the setting of anti-Xa or anti-thrombin inhibitors, PCCs may be used, however, they have been shown to have variable outcomes and therefore may be less effective than expected [11].
Primary Postpartum Haemorrhage
Published in Sanjeewa Padumadasa, Malik Goonewardene, Obstetric Emergencies, 2021
Sanjeewa Padumadasa, Malik Goonewardene
These include inherited coagulation disorders, secondary coagulopathies including disseminated intravascular coagulation (DIC) and the use of anticoagulants. Inherited coagulation disorders do not contribute significantly to primary PPH, because the main mechanism of arresting bleeding following delivery is the contraction of the uterus. In addition, the changes in the coagulation system which occur during pregnancy favour blood clotting. However, women with inherited coagulation disorders may present with secondary PPH (discussed in Chapter 15).
Vascular anomalies
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
Eileen M. Duggan, Steven J. Fishman
In patients with certain anomalies that are more high-risk (e.g. multifocal or extensive VMs, LVMs, CLVMs), we recommend more extensive preoperative hematologic evaluation. These patients are more likely to have chronic consumptive coagulopathies. While the coagulopathy does not normally cause serious problems at baseline, it can worsen with surgical resection or other major procedures and lead to serious systemic bleeding and thrombotic complications. Therefore, preoperative plasma d-dimer, fibrinogen, platelets, PT, and PTT should be drawn. Concerning numbers include a d-dimer more than 20 times the upper limit, fibrinogen levels <100 mg/dL, elevated PT or PTT, and thrombocytopenia. In cases of lab abnormalities, replacement therapy with platelet or cryoprecipitate should be given perioperatively to keep fibrinogen greater than 100 mg/dL and platelet counts over 100 000/μL. The administration of low-molecular weight heparin may bring fibrinogen to normal levels without the need for cryoprecipitate.
Data-driven monitoring in patients on left ventricular assist device support
Published in Expert Review of Medical Devices, 2022
Lieke Numan, Mehran Moazeni, Marish I.F.J. Oerlemans, Emmeke Aarts, Niels P. Van Der Kaaij, Folkert W. Asselbergs, Linda W. Van Laake
On the other side of the spectrum there is an increased bleeding risk, which instead may lead to a decreased power, flow, and increased PI (Table 1). Also, the circadian rhythm of power and flow may diminish [21]. It can have several causes, such as intrinsic coagulopathies or over-anticoagulation for example due to liver congestion. Moreover, there is an increased risk for a bleeding event following treatment of a thrombotic event due to cessation of anticoagulation therapy [22]. However, bleeding complications such as a hemorrhagic stroke are not caused by anticoagulation therapy alone, as a supra therapeutic INR is neither necessary nor sufficient to cause a hemorrhagic stroke [23]. In addition, patients on LVAD support often suffer from acquired von Willebrand syndrome, where the Von Willebrand Factors (VWF) are structurally misshaped due to increased shear stress, leading to an increased bleeding risk. Bleeding in the gastro-intestinal tract (GI) often occurs at the location of an arteriovenous malformation (AVM) that arise as a consequence of diminished pulsatility [24]. No studies specifically focused on detecting such patterns in pump power, but algorithms developed for pump thrombosis may be applicable as well.
Emerging therapeutic targets for sepsis
Published in Expert Opinion on Therapeutic Targets, 2021
Elizabeth W. Tindal, Brandon E. Armstead, Sean F. Monaghan, Daithi S. Heffernan, Alfred Ayala
A spectrum of coagulopathies has been found in patients with sepsis, ranging from mild derangements to DIC, and are believed to be fundamental to the development of end-organ dysfunction and ultimately mortality. Yamakawa et al. found that in a small group of patients with sepsis-induced DIC administration of rhTM resulted in significant improvement in organ dysfunction as marked by Sequential Organ Failure Assessment (SOFA) scores and a significant reduction in 28-day mortality versus controls [37]. A subsequent study by Kato et al. focused on septic patients with mild versus severe coagulopathy and, once again, found an improvement in SOFA scores, especially the respiratory component, and 90-day mortality amongst those in the severe group [38]. However, the SCARLET trial, which was a randomized controlled trial involving over 800 patients with sepsis-associated coagulopathy, failed to show a benefit in terms of 28-day mortality (Table 1) [39]. Despite this, a recent study by Yoshihiro et al. focused on sepsis patients with severe respiratory failure rather than a coagulopathy and found a reduction in both ICU and hospital mortality rates in comparison to those who did not receive rhTM [40].
Long-Term Management of Vascular Access Ports in Nonhuman Primates Used in Preclinical Efficacy and Tolerability Studies
Published in Journal of Investigative Surgery, 2020
Lucas A. Mutch, Samuel T. Klinker, Jody J. Janecek, Melanie N. Niewinski, Rachael M. Z. Lee, Melanie L. Graham
All animals should be evaluated prior to implantation for suitability for port placement; animals with active infection or bacteremia, neutropenia, coagulopathies or anticoagulant use require special consideration. Animals with active infection or bacteremia should not be implanted with a VAP, any infection should be treated appropriately and completely resolved before implantation is considered. In immunosuppressed NHPs, a neutrophil count <1000/μL, may increase the potential for sepsis and generally implantation should be delayed until neutropenia is resolved. Naturally occurring coagulopathies are rare in healthy NHPs, but induced disease may prompt clotting disorders. Likewise animals may require anticoagulant therapy as a matter of study course, which should be evaluated, and adjusted if necessary, prior to implantation. Finally, evaluate the intended insertion site evaluated for suitability. Venous occlusion, thrombosis, prior use of site, trauma, anatomic constraints (size), may restrict port placement.