China
Africa
Explore chapters and articles related to this topic
Head Injury
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
Many elderly patients are on warfarin. With a near-patient coagulation check, most advanced services will now administer prothrombin complex concentrate to reverse this if there is significant risk of head injury. More patients are now taking direct oral anticoagulants. These are more difficult to reverse in the acute phase and it is best to seek local guidelines. Cooling of patients to lower cerebral metabolic rate has traditionally been advocated as neuroprotective, and indeed there is good evidence that cooling during cardiac arrest does benefit neuronal survival27. However, recent studies have not shown such benefit either on intensive care28 or in the pre-hospital environment for TBI.29
Haematology
Published in Faye Hill, Sash Noor, Neel Sharma, Tiago Villanueva, Medical and Surgical Emergencies for Students and Junior Doctors, 2021
Faye Hill, Sash Noor, Neel Sharma
Treatment relies on management of the underlying condition. Platelet transfusion should be instigated in those with DIC and bleeding as well as a platelet count of less than 50 × 109/L. In bleeding patients with DIC, a prolonged prothrombin time and activated partial thromboplastin time, fresh frozen plasma should be administered. If administration of fresh frozen plasma is not possible, prothrombin complex concentrate is a suitable alternative. Severe hypofibrinogenaemia that persists despite fresh frozen plasma replacement can be treated with fibrinogen concentrate or cryoprecipitate.
Transfusion products
Published in Jennifer Duguid, Lawrence Tim Goodnough, Michael J. Desmond, Transfusion Medicine in Practice, 2020
Traditionally, plasma has been fractionated to provide albumin, factor VIII and IX concentrates, and immunoglobulins. However, the range of products has been extended in recent years to include, for example, antithrombin III, prothrombin complex concentrate, and activated protein C. Isolation of individual proteins is primarily based upon the solubility differences using the principles developed by Edwin Cohn in 1925 and chromatography.
Key questions in the new hemophilia era: update on concomitant use of FVIII and emicizumab in hemophilia A patients with inhibitors
Published in Expert Review of Hematology, 2021
Manuel Carcao, Maria Elisa Mancuso, Guy Young, Víctor Jiménez-Yuste
The main argument favoring a continued strategy of inhibitor eradication is that patients receiving emicizumab still require hemostatic treatment to treat bleeds (which do occur albeit not often), to manage traumas, and to cover surgical procedures. Bypassing agents and FVIII have been used for these purposes in patients receiving emicizumab prophylaxis. However, thrombotic complications including venous thromboembolism and thrombotic microangiopathy (TMA) have been reported with concurrent use of emicizumab and activated prothrombin complex concentrate (aPCC) at a dose greater than 100 U/kg for more than 1 day [8]. Although thrombotic/TMA events have not been reported with FVIII or rFVIIa in conjunction with emicizumab, aligning with in vitro data [12], inhibitor patients with a poor hemostatic response to rFVIIa require rescue with a PCC putting them at risk of thrombotic/TMA events. Thus, the safest and most effective approach for emicizumab-treated patients requiring hemostatic augmentation (for surgery, treatment of bleeds) is FVIII replacement therapy, which is possible only in the absence of an inhibitor. Inhibitor patients who are not offered ITI may have lifelong reliance on bypassing agents for hemostatic control which is not ideal given their lower efficacy, convenience and safety, and higher costs relative to FVIII replacement therapy (Table 1).
Thrombotic complications in adult patients with severe single coagulation factor or platelet defects – an overview
Published in Expert Review of Hematology, 2019
Hanne Skaadel, Øystein Bruserud
The risk of thrombosis may also depend on the factor preparation used, at least when using plasma-based preparations that may differ considerably in purity [8]. Previous studies have compared the effect of prothrombin complex concentrates and purified factor IX concentrates in patients with factor IX deficiencies; activation of the coagulation system with increased levels of prothrombin fragment 1 + 2 (a measure of factor Xa activity), fibrinopeptide A (a measure of thrombin activity), and thrombin–antithrombin complexes was then observed when using prothrombin complex concentrate but not after infusion of a highly purified concentrate [9–11]. Taken together these observations suggest that the activation of the coagulation system and thereby the risk of thrombosis for patients receiving substitution therapy also depend on the factor preparation used, at least when using plasma-derived preparations.
Major bleeding with apixaban in atrial fibrillation: patient characteristics, management, and outcomes
Published in Hospital Practice, 2018
Sarah Eisho, Nouran M. Salem, Janet L. Hoffman, John M. Koerber, Maureen A. Smythe
All patients had interruption in anticoagulant therapy and over 80% of patients received PRBC transfusion. Fresh frozen plasma (FFP) was infrequently administered (6%). The American College of Cardiology (ACC) states FFP is not indicated in DOAC reversal while the EHRA indicates FFP may be considered as a plasma expander (not a reversal agent) for those with non-life threatening major bleeding [22,23]. Activated prothrombin complex concentrate, a non-specific reversal agent recommended by ACC and the EHRA for major/life threatening bleeding, was also infrequently used (6%). With the recent approval of Andexxa® in the United States and the pending decision by the EMA, the role of coagulation factors in direct Xa reversal will need to be re-evaluated once a sustainable supply of Andexxa is available. It is noteworthy that in the absence of a specific reversal agent for apixaban, the in-hospital mortality in this study for apixaban major bleeding was 0%. Anticoagulation was held at discharge in 64% of patients, and remained on hold at 30 days post-discharge in 75% of these patients. Two patients developed a thrombotic event while off anticoagulation. In ARISTOTLE, apixaban was resumed after a GI bleed in 63% of patients with a median hold time of 15 days [3]. In patients with a GI bleed, restarting anticoagulant therapy after day seven as compared to day 30 is associated with a reduction in thromboembolism and mortality without an increase in recurrent GI bleed risk [24]. The assessment of re-initiation of apixaban therapy post discharge is an important component of patient management.