Bleeding Complications Research Articles

The potential impact of COVID-19 vaccination on patients with immune thrombocytopenic purpura: A protocol for systematic review and meta-analysis.

Immune thrombocytopenic purpura (ITP) is a disease characterized by a decrease in platelet count, which can be triggered by various factors, including viral infections and vaccination. With the widespread vaccination against COVID-19, concerns have arisen regarding a possible link between the vaccine and the exacerbation of ITP. This study aims to comprehensively evaluate the impact of COVID-19 vaccination on ITP patients, including associated risks and outcomes. A comprehensive search will be conducted in multiple electronic databases (including PubMed, Web of Science, EMBASE, Cochrane Library, CNKI, Wan Fang, VIP, and CBM) to identify relevant studies. This study will include randomized controlled trials, cohort studies, case-control studies, and case series evaluating the impact of COVID-19 vaccination on ITP patients. The primary outcome measure is the change in platelet count, while secondary outcome measures include the occurrence of thromboembolic events, bleeding complications, ITP recurrence rate, impact of ITP exacerbation, and adverse events. Data will be summarized and analyzed using Review Manager Software (RevMan) V.5.4. In addition, subgroup analyses will be performed to explore potential sources of heterogeneity. It is anticipated that different types of COVID-19 vaccines may have varying impacts on ITP patients, leading to potential differences in outcomes. This study aims to comprehensively evaluate the potential impact of COVID-19 vaccination on ITP patients and provide reference for clinical decision-making. The results of this systematic review and meta-analysis will provide crucial information on COVID-19 vaccination for ITP patients and clinicians, contributing to guiding vaccination decisions and monitoring potential impacts after vaccination.

Outcomes and Adverse Effects of Transcatheter Aortic Valve Replacement (TAVR) in Cancer Patients: A Meta-Analysis.

Aortic valve disease and cancer are significant causes of mortality, especially in older populations. This meta-analysis addresses a critical question in the management of patients with both aortic valve disease and cancer. As these two conditions are major contributors to mortality, determining the best course of treatment can be complex. Traditionally, randomized controlled trials (RCTs) exclude cancer patients, leaving a gap in clinical evidence. This study steps in to fill that gap by pooling data from over 120,000 patients in 15 cohort studies, following PRISMA guidelines to evaluate the safety and effectiveness of transcatheter aortic valve replacement (TAVR) in cancer patients. The primary focus of the analysis was all-cause mortality, withsecondary outcomes including stroke, pacemaker implantation, acute kidney injury, major bleeding, and vascular complications. The results revealed no statistically significant differences between cancer and non-cancer groups in terms of mortality or complications. These findings suggest that TAVR can be a safe and effective option for patients with cancer, suggesting that deferring cardiovascular interventions in favor of cancer treatment may not always be necessary. However, the observational nature of the included studies does introduce potential biases, such as confounding factors and selection bias. The study highlights the need for more targeted research that focuses on specific types and stages of cancer to better understand how these factors may influence outcomes. Despite these limitations, the meta-analysis provides valuable insights and suggests that TAVR could be a viable treatment path for patients managing both cancer and aortic valve disease.

Evolution and Impact of Hepatitis A Epidemiology in Europe-Systematic Literature Review of the Last 20 Years.

While globally hepatitis A (hepA) infections occur in 150 million people annually, European high-income countries now have a low endemicity. However, this results in a more susceptible adult population which is prone to severe illness. To determine current epidemiological characteristics, we performed a systematic literature review to assess the severity of hepA disease in the past two decades in 11 European countries (i.e., Denmark, France, Germany, Greece, Hungary, Italy, the Netherlands, Spain, Sweden, Switzerland and the United Kingdom). Literature search was performed using PubMed and Embase between 1 January 2001 and 14 April 2021. Search terms included the disease (hepA), the 11 selected countries, the term 'outbreaks' and its synonyms, outcomes and terms for hepA virus circulation. In total, 43 records reported data on hepA disease outcomes. Hospitalisation rates varied between the countries, with annual rates exceeding 50% at least once in seven countries. The lowest hospitalisation rates were reported for the Netherlands (≤ 32%) and the highest for Greece (≥ 81%). Liver failure, haemorrhagic and other complications were rarely reported, and case fatality rates were low (0.03%-0.26%). Our findings are consistent with the trends observed globally. This systematic literature review highlights the need to increase awareness of hepA risks and to strengthen prevention strategies. Continuous monitoring of epidemiological data is crucial to assess which populations would most benefit from prevention, mainly with respect to future vaccination recommendations.

Real-world data on direct oral anticoagulants in BCR::ABL1-negative myeloproliferative neoplasms (MPNs): a multicenter retrospective study on behalf of scientific subcommittee on MPNs for Turkish society of hematology.

BCR::ABL1-negative myeloproliferative neoplasms (MPNs) pose a substantial risk of thrombosis, leading to significant morbidity and mortality. Anticoagulant therapy, historically based on vitamin K antagonists (VKAs), has limitations in preventing recurrent thrombotic events and managing bleeding complications. Direct oral anticoagulants (DOACs) offer a potential alternative with improved pharmacokinetics and compliance. However, evidence on DOAC efficacy and safety in MPNs remains limited, necessitating further investigation. In this multicenter retrospective study in Türkiye, we assessed real-world usage patterns and outcomes of DOACs in MPN patients. Data from 220 patients with PV, ET, or PMF receiving DOACs or VKAs for thrombosis or nonvalvular atrial fibrillation (NVAF) were collected from medical records. Thrombotic events and bleeding episodes were documented based on ISTH criteria. DOACs were used in 126 patients as first-line anticoagulant therapy or following VKAs. Ninety-four patients were on VKAs, of which 83 as a first-line treatment. There were eight thromboses (6.3%) seen in 126 DOAC patients, and similarly, seven episodes (9.4%) of thrombosis were observed in 94 patients using VKA. Major bleeding occurred in seven patients (5.6%) on DOAC and 3 (3.2%) in VKA. Thrombotic and bleeding risks were comparable between DOACs and VKAs (p = 0.708 and p = 0.158, respectively). The incidence rate of thrombosis in the VKA group is 1.1% and in the DOAC group is 1.9%. The incidence of major bleeding in the VKA group is 0.6% and 1.6% in the DOAC group. To the best of our knowledge, our study included the largest number of MPN patients to date, comparing DOACs with VKA in terms of both efficacy and safety, which suggests DOACs as promising alternatives to VKAs for managing thrombotic risk in MPNs with manageable toxicity. Despite the limitations of retrospective studies, DOACs' benefits in terms of efficacy and compliance warrant further investigation through prospective trials. Individualized treatment decisions should consider patient-specific factors, emphasizing collaborative efforts between specialists to optimize DOAC therapy in patients with MPNs. Comparable efficacy and safety between DOACs and VKAs were observed in MPN patients.

Manual Uterine Aspiration Simulation for Emergency Medicine Learners.

Manual uterine aspiration is a potentially lifesaving procedure for treating patients with hemorrhagic complications of early pregnancy loss. While early pregnancy loss is a common diagnosis seen in the emergency department, manual uterine aspiration education is lacking for emergency medicine physicians. We designed a 90-minute procedural skills training session for 30 emergency medicine learners. The session included a brief lecture and video demonstration, followed by two micro-skills stations before finally completing the simulated procedure in its entirety. At each station, learners were asked to verbalize the steps and landmarks for the procedure before performing them on models. Participants completed a combined pre-post survey evaluating their perceived knowledge of the procedure and self-efficacy in performing the procedure. Thirty learners who participated in the workshop were surveyed, with a 100% response rate. All participants reported increased comfort with the procedure and knowledge about the procedure. All participants completed a successful simulated procedure. Participants also indicated increased interest in learning more about manual uterine aspiration and its potential application within the emergency medicine physician's scope of practice. We developed a workshop to train emergency medicine learners in manual uterine aspiration to stop life-threatening hemorrhage in the setting of early pregnancy loss. The workshop was well received by learners and increased their self-efficacy and desire for additional training with this procedure. Similar curricula should be tried at other institutions.

The Role of Robotic Cystectomy in the Salvage and Palliative Setting: A Retrospective, Single-Center, Cohort Study

Introduction: This article compares surgical and survival outcomes of robot-assisted and open radical cystectomy with cutaneous ureterostomy for the treatment of frail bladder cancer patients with limited life expectancy. Methods: The institutional database was searched for cystectomy cases with cutaneous ureterostomy, from 1 June 2016 to 31 August 2022. The study population was split into two groups, according to the surgical approach. The baseline characteristics and surgical outcomes were compared. Logistic regression analyses identified predictors of major bleeding events (hemoglobin loss ≥ 3.5 g/dL or blood transfusion) and re-operation within 30 days from surgery. The Kaplan–Meier method estimated the impact of the robotic approach on overall survival and Cox regression analysis assessed its predictors. Results: A total of 145 patients were included: 30% (n = 43) underwent robotic cystectomy. Patients’ characteristics and tumor stages distribution were comparable in the two groups but those receiving a minimally invasive treatment showed significantly reduced times to flatus, bowel and hospital discharge (all p < 0.001). Although operation times were longer in this cohort, major bleeding events (60% vs. 89%) and postoperative severe complications (0 vs. 8%) (both p < 0.001) were less frequent compared to the open approach. A logistic regression showed that robotic surgery independently predicted major bleeding events (OR: 0.26; 95%CI 0.09–0.72; p = 0.02) but not the need for re-intervention. A Kaplan–Meier analysis showed that robotic cystectomy was associated with a significant advantage in terms of overall survival (LogRank = 0.03), and this result was confirmed by Cox regression analysis (HR: 0.39; 95%CI 0.14–0.94; p = 0.04). Conclusions: Robotic cystectomy with cutaneous ureterostomy may represent a viable option to treat frail bladder cancer patients, as the minimally invasive approach reduces the risk of bleeding and serious complications and provides a prompt restoration of bowel function and a shorter hospital stay compared to open surgery.

TICA-CLOP STUDY: Ticagrelor Versus Clopidogrel in Acute Moderate and Moderate-to-Severe Ischemic Stroke, a Randomized Controlled Multi-Center Trial.

Many studies evaluated the efficacy and safety of ticagrelor versus clopidogrel in patients with ischemic stroke; none of these trials included North African participants, and all of these trials comprised only participants who experienced transient ischemic attack (TIA) or minor stroke. We compared the efficacy and safety of ticagrelor versus clopidogrel in patients with first-ever noncardioembolic moderate or moderate-to-severe ischemic stroke. Our trial involved 900 first-ever noncardioembolic patients with acute ischemic stroke (AIS) who randomly received either loading and maintenance doses of ticagrelor or clopidogrel within the first 24 h of stroke onset. We involved 900 patients in the intention-to-treat analysis. A total of 39 (8.7%) patients in ticagrelor arm and 62 (13.8%) in clopidogrel arm experienced a new stroke [hazard ratio (HR) 0.46; 95% confidence interval (CI) 0.34-0.83; P value = 0.006]. A total of 57 (12.7%) patients in ticagrelor group and 80 (17.8%) patients in clopidogrel group experienced composite of new stroke, myocardial infarction (MI), or death due to vascular insults (HR 0.51; 95% CI 0.43-0.82; P value = 0.004). Participants who received ticagrelor experienced less frequent unfavorable outcomes. We found no significant variation between our study's two arms concerning the hemorrhagic and non-hemorrhagic complications. Patients with noncardioembolic moderate or moderate-to-severe ischemic stroke who received ticagrelor within the first 24 h after ischemic stroke had better clinical outcomes based on recurrent stroke rates and unfavorable modified Rankin Scale (mRS) rates compared with those who received clopidogrel. There were no significant variations between ticagrelor and clopidogrel regarding hemorrhagic and non-hemorrhagic complications. ClinicalTrials.gov identifier number NCT05553613.

Methodological Considerations for Studies Evaluating Bleeding Prediction Using Hemostatic Point-of-Care Tests in Cardiac Surgery

A certain proportion of patients undergoing cardiac surgery may experience bleeding complications that worsen outcomes. Numerous studies have investigated bleeding in cardiac surgery and some evaluate the role of hemostatic point-of-care tests in cardiac surgery patients. The prevalence of excessive bleeding varies in the literature, and such variability stems from the lack of a standardized definition of excessive bleeding. Herein, we report numerous definitions of excessive bleeding and methodological considerations for studies evaluating bleeding using hemostatic point-of-care tests in cardiac surgery patients. We evaluated the role of hemostatic point-of-care devices in contemporary research on bleeding complications and hemostatic management in cardiac surgery. The type of studies (prospective vs. retrospective, interventional vs. observational), patient selection (less complex vs. complex cases), as well as data analysis with comprehensive statistical considerations have also been provided. This article provides a comprehensive insight into the research field of bleeding complications in cardiac surgery and may help readers to better understand methodological flaws and how they influence current evidence.

Multidisciplinary Guidance for the Management of Severe Bleeding on Oral Anticoagulation: An Algorithm for Practicing Clinicians.

Bleeding complications associated with oral anticoagulant (OAC) frequently lead to emergency department visits and hospitalization. Short-term all-cause mortality after severe bleeding is substantial ranging from about 10% for gastrointestinal bleeding (the most frequent single site) to about 50% for intracranial bleeding. A protocolized, multidisciplinary approach to bleeding ensures is needed to (i) rapidly identify of patients at risk of adverse outcomes, (ii) optimize delivery of supportive measures, (iii) treat the source of bleeding, and (iv) administer anticoagulant reversal or hemostatic therapies judiciously for patients most likely to benefit. We convened a multidisciplinary panel of experts (emergency medicine, gastroenterology, general internal medicine, hematology, neurology, pharmacy, thrombosis,) to review the literature and provide practical guidance including a corresponding algorithm for use at the point of care to assist clinicians in the management of patients with acute severe OAC-related bleeding.

The Many Faces of Immune Thrombocytopenia: Mechanisms, Therapies, and Clinical Challenges in Oncological Patients

The pathogenesis of immune thrombocytopenia (ITP) is complex and involves the dysregulation of immune cells, such as T and B lymphocytes, and several cytokines that promote the production of autoantibodies. In the context of cancer patients, ITP can occur in both primary and secondary forms related to anticancer therapies or the disease itself. Objective: In light of these data, we decided to prepare a literature review that will explain the classification and immunological determinants of the pathogenesis of ITP and present the clinical implications of this condition, especially in patients with cancer. Materials and methods: We reviewed the literature on immunological mechanisms, therapies, and challenges in treating ITP, particularly on cancer patients. Results: The results of the literature review show that ITP in cancer patients can be both primary and secondary, with secondary ITP being more often associated with anticancer therapies such as chemotherapy and immunotherapy. Innovative therapies such as TPO-RA, rituximab, Bruton’s kinase inhibitors, and FcRn receptor inhibitors have shown promising results in treating refractory ITP, especially in patients with chronic disease. Conclusions: ITP is a significant clinical challenge, especially in the context of oncology patients, where both the disease and treatment can worsen thrombocytopenia and increase the risk of bleeding complications. Treatment of oncology patients with ITP requires an individualized approach, and new therapies offer effective tools for managing this condition. Future research into immunological mechanisms may bring further advances in treating ITP and improve outcomes in cancer patients.

Preoperative bleeding risk assessment in cardiac surgery patients

One of the most important aspects in achieving successful outcomes in cardiac surgery is the evaluation of the risk of bleeding during and after the procedure. Preoperative anemia, intraoperative bleeding, and transfusion therapy contribute to a cumulative risk of adverse events. Given the limitations of traditional coagulation tests, a more comprehensive and patient-centered approach is necessary. Factors affecting the risk of bleeding should be considered from the perspective of both individual patient characteristics and the specific type and extent of the planned surgical intervention. The risk assessment should be informed by individual and familial history, as well as previous episodes of bleeding or other relevant information. The use of bleeding risk scales can play a crucial role in this process, providing valuable insights into the likelihood of bleeding complications. In conclusion, a comprehensive approach that takes into account the unique characteristics of each patient and the specific details of the surgical procedure is essential for minimizing the risk of complications and ensuring successful outcomes.

Blood Loss in Women of Childbearing Potential Taking Oral Anticoagulants for Venous Thromboembolism (The BLEED Study).

Oral anticoagulants (OAC) may exacerbate menstrual bleeding in women of childbearing age; however, the existing literature on this issue has several limitations. This study investigates abnormal uterine bleeding (AUB) in women of childbearing age taking oral anticoagulants-Vitamin K antagonists (VKA) or Direct Oral Anticoagulants (DOAC)-for venous thromboembolism through a retrospective analysis of prospectively collected data. Uterine bleeding was assessed using the Pictorial Blood Assessment Chart (PBAC) and hemoglobin (Hb) values during anticoagulation compared to prior therapy. The number of unplanned medical visits for bleeding complications was also calculated. From June 2014 to November 2023, 110 women were recruited (median age, 36 years). PBAC scores correlated with Hb values at baseline and during therapy (ANOVA, p<0.01), with a significant difference in Hb values before and during anticoagulant therapy (Δ Hb) among groups (ANOVA, p=0.034). Seventeen women (15.4%) reported fibroids, experiencing a greater reduction in Hb values during anticoagulant administration than women without fibroids (Δ 0.3, IQR -0.8, 2.9 vs -0.5, IQR -1.2, 0.3; p=0.012). Women with fibroids required more frequent unplanned medical consultations for bleeding (mean visits 5 vs 4 respectively; Poisson regression, p<0.05). Among women with fibroids, those taking apixaban showed smaller Hb changes than those on other oral anticoagulants (ANOVA, p=0.047). This difference persisted even after adjusting for potential confounders (MANOVA, p=0.004). Women of childbearing potential taking OAC frequently experience changes in Hb values and PBAC scores during treatment, with fibroids playing a significant role.

Pregnant Woman in Outcomes with Prosthetic Heart Valves

We here sought to assess thrombotic and hemorrhagic complications and associated risk factors during pregnancy, delivery, and postpartum in women with prosthetic heart valves (PHV). Methods: The retrospective cohort study covered January 2011 to December 2022. The objective of the study was to assess the risk factors and frequency of thrombotic and hemorrhagic complications during pregnancy, delivery, and the postpartum period in women with PHV based on the experience of one perinatal center. We included 88 pregnancies with 77 prosthetic heart valves (PHV), which were divided into two groups, mechanical valve prostheses (MVP) (n = 64) and biological valve prosthesis (BVP) (n = 24). In the study we analyzed pregnancy outcomes, as well as thrombotic and hemorrhagic complication frequencies. Results: Of 88 pregnancies, 79 resulted in live births. In the MVP group, there were six miscarriages (9.4%) and two medical abortions (3.1%), including one due to Warfarin’s teratogenic effects. No miscarriages were reported in the BVP group, but one fetal mortality case (4.2%) occurred. During pregnancy, 11 MVP cases (17.2%) experienced thrombotic complications. In the BVP group, one patient (4.2%) had transient ischemic attack (TIA). Two MVP cases required surgical valve repair during pregnancy, and one in the post-delivery stage was caused by thrombotic complications. Postpartum, two MVP cases had strokes, and in one MVP patient, pulmonary embolism was registered, while no thrombotic complications occurred in the BVP group. Hemorrhagic complications affected 15 MVP cases (17.9%) in the postpartum period. There were no registered cases of maternal mortality. Conclusions: The effective control of anti-factor Xa activity reduced thrombotic events. However, the persistently high incidence of postpartum hemorrhagic complications suggests a need to reassess anticoagulant therapy regimens, lower target levels of anti-Xa, and reduce INR levels for discontinuing heparin bridge therapy. Despite the heightened mortality risk in MVP patients, our study cohort did not have any mortality cases, which contrasts with findings from other registries.

Antithrombotic Agents After Free Tissue Transfer in the Pediatric and Adolescent Population.

Even for the experienced microsurgeon, free tissue transfer in pediatric patients is challenging, and large patient series remain scarce in the literature. Moreover, the added value of antithrombotic agents in pediatric free tissue transfer remains unclear. We conducted a retrospective outcome analysis of pediatric free tissue transfer with respect to postoperative antithrombotic treatment at our tertiary academic center. All patients aged 0 to 18 years who underwent free tissue transfer from 1998 to 2022 were included in the study. Seventy patients received 73 free tissue transfers. The most common indications were facial paralysis, trauma, and tumor (49.3%, 21.9%, and 20.5%, respectively). The most common recipient sites were the head and neck (56.1%) and lower extremity (32.8%). We observed a flap revision rate of 12.5% of the cases and one flap loss (1.4%). 58.9% of the population received post-operative antithrombotic agents. The rate of flap revision surgery was similar (11.6% and 10.0%, respectively), with and without antithrombotic treatment (p>0.05). There were no major bleeding complications or deep vein thrombosis. The antithrombotic treatment did not seem to affect the flap revision rate or the bleeding complications in our cohort. Hence, the data do not support the routine administration of antithrombotic treatment in pediatric free flap reconstruction. However, these findings should be solidified in prospective randomized trials.

Haemorrhagic and thromboembolic outcomes in pregnant patients with mechanical heart valves who undergo interruption of anticoagulation for birth - A case series.

Anticoagulant therapy prevents thrombosis and thromboembolic events in patients with mechanical heart valves. Bridging anticoagulation around the time of birth represents a unique challenge. Few retrospective reviews or case series exist examining peripartum outcomes with bridging anticoagulation. Review of peripartum and postpartum anticoagulation management, with a focus on postpartum complications. Design: case series, single centre. Royal Brisbane and Women's Hospital, Australia between 1 January, 2000, and 1 August, 2022. all pregnant women with mechanical heart valves (any type) who birthed. intrapartum and postpartum haemorrhage, thrombosis, thromboembolic complications, cardiac events, readmission, and maternal death. There were 18 women, with 23 births. Sixteen births were via caesarean section (70%). Fourteen women (61%) experienced at least one significant haemorrhagic complication, one woman required a peripartum hysterectomy, one woman experienced atrial fibrillation, and one had a valvular thromboembolic complication. No maternal cerebral thromboses or maternal deaths were recorded. Women with mechanical heart valves who undergo bridging anticoagulation are associated with significant maternal morbidity. Most postpartum haemorrhagic complications were associated with bridging unfractionated heparin infusions in the first postnatal week. Bridging anticoagulation practices varied widely. Ongoing pooled data are required to inform evidence-based guidelines for postpartum anticoagulation management.

Middle meningeal artery embolization and tranexamic acid therapy for subdural hematoma in a patient with hereditary hemorrhagic telangiectasia: illustrative case.

Subdural hematoma is a rare manifestation of hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease. Here, the authors present a patient with HHT and a large chronic subdural hematoma, for whom nonsurgical management was pursued. A 49-year-old right-handed male with a history of hypertension and familial HHT presented with complaints of mild confusion and left hemiparesis over several days. Noncontrast head computed tomography images demonstrated a large chronic right hemisphere subdural hematoma compressing the right cerebral hemisphere and causing a 1.3-cm midline shift. Due to concerns about surgical complications arising from hemorrhages of cryptic telangiectasias, the patient was treated conservatively with middle meningeal artery embolization and adjuvant tranexamic acid. There was clinical and radiological resolution several months later. This case highlights the rarity of a subdural hematoma as a manifestation of HHT and the nonsurgical treatment strategy as a mechanism to avoid hemorrhagic complications of surgical evacuation. https://thejns.org/doi/10.3171/CASE24483.

Ultrasound-guided popliteal sciatic nerve block for surgical anesthesia in wound care patients with ongoing anticoagulant/antiaggregant therapy: A single-center, prospective study.

Ultrasound-guided peripheral nerve blocks may be a good alternative in patients under antithrombotic drugs. We evaluated the efficacy of ultrasound-guided popliteal sciatic nerve block in patients undergoing lower extremity wound debridement of whom antithrombotic drugs could not be stopped. We focused on hemorrhagic complications related to sciatic nerve block. Wound care patients followed by Cardiovascular Surgery Department scheduled for lower extremity wound surgery were included in this prospective observational study. Data was collected between March 2021 and September 2022. All patient were under antithrombotic therapy and discontinuation of anticoagulant drugs were not possible. Single-insertion and multiple-injection sciatic nerve block at popliteal region was applied to all patients under ultrasound guidance. Primary outcome was the rate of hemorrhage. Secondary outcomes were block onset times, block success and postoperative analgesia times. Data of 105 patients was evaluated, 87 were male and 18 were female. Mean patient age was 61.92 ± 10.06, mean patient body mass index was 25.68 ± 6.33. All patients were under 1 or more antithrombotic drugs. Only one minor hematoma was detected by postoperative ultrasonography control in 1 patient. Hemorrhage complication rate was 1 of 105 (% 0.95, 95% CI, 0.00024-0.051). Overall block success rate was 99.05%. Mean block onset time was 16.27 ± 5.69 minutes. Mean postoperative analgesia time was 19.5 ± 11.22 hours. Sciatic nerve block under ultrasound guidance using in-plane technique was safe and provided sufficient surgical anesthesia and postoperative analgesia for lower extremity wound debridement surgery in patients on antithrombotic drugs.

Oral invasive procedures in Glanzmann Thrombasthenia: a retrospective observational study

BackgroundGlanzmann Thrombasthenia (GT) is a very rare inherited autosomal bleeding disease affecting megakaryocyte lineage with impacts on oral health such as gingival bleeding and requiring specific management protocols. Only very few clinical cases have been published in the dental and hematological literature. ObjectivesThis study focuses on a series of 21 patients affected specifically by GT and their hemorrhagic prophylaxis management with the use of recombinant factor VIIa (rFVIIa) for dental extractions and full-mouth debridement. Results41 full-mouth debridement and 176 dental extractions were performed along 102 sessions of dental care in outpatient setting. A total of 226 injections of rFVIIa was delivered. The mean of injection was 2.2 (range 1 to 4) per dental procedure. The overall rate of bleeding complication was 5.9% (n = 6). All of these six hemorrhagic complications were classified as minor bleeding. No thromboembolic event was observed nor allergic reaction. ConclusionThe data presented in this retrospective observational study support the efficacy and safety of rFVIIa for the prevention of bleeding for invasive dental procedures in patients affected by GT. rFVIIa protocol presented here seems to be a safe and efficient protocol for the prevention of bleeding for invasive oral procedures.

Developing a veno-venous extracorporeal membrane oxygenation program during the COVID-19 pandemic: don’t forget to notify the blood bank

ObjectivesDuring the SARS-CoV-2 pandemic, there has been significant increased use of vvECMO as rescue therapy. Patients with COVID-19 as anticoagulation is needed for vvECMO support, may develop bleeding complications requiring an increased number of RBC transfusions. We would like to report the RBC transfusion needs following the implementation of an ECMO program. Data on blood usage in this population is important in view of the decline in donations due to the pandemic.Study Design and Methods: We analyzed data on RBC transfusions in patients who required vvECMO for COVID-19 related ARDS in a Belgian ICU from March 2020 to March 2022. The primary end point was RBC transfusion requirements. and the relationship to outcome. We also analyzed the evolution of this requirement during the four waves. ResultsWe admitted 538 patients for hypoxemic ARDS due to COVID-19. Sixty patients (11%) required vvECMO, of whom 27 (45%) died. Forty-seven (78 %) of the vvECMO patients were transfused a total of 403 packed RBC units.. Sites of hemorrhagic complications were ECMO cannulation sites and lungs. RBC transfusion per patient per day on vvECMO was 0.50 [0.30-0.67] units. There were no differences in hemorrhagic complications in vvECMO survivors and non-survivors.The percentage of vvECMO patients receiving a RBC transfusion increased slightly during the last COVID-19 wave, with 92 % of patients transfused. ConclusionsvvECMO program is associated with a major need for RBC transfusions. These data are important when blood availability is decreased due to a pandemic and illustrates the need for studies on optimizing blood management including therapeutic anticoagulation target, threshold for RBC transfusion or alternatives to RBC transfusion.

Anticoagulation management in gynecologic brachytherapy patients with perioperative or chronic thromboembolic disease: A retrospective analysis

Women on chronic anticoagulation (AC) who require operative brachytherapy for gynecologic malignancies represent a clinical challenge, but no guidelines exist regarding patient selection for brachytherapy or their perioperative management. We aimed to understand the incidence of hemorrhagic and embolic events in our patients on chronic AC and suggest management strategies for this patient population. A retrospective, single institutional study of patients treated with operative, gynecologic brachytherapy from 2013 to 2023 was performed to identify patients on chronic AC. We determined indications for AC use, oncologic therapy characteristics, duration of AC interruption, and therapy outcomes. The primary aim was to determine perioperative embolic or hemorrhagic complications as measured by the Common Terminology Criteria for Adverse Events. Of 304 patients treated with operative implants, 32 (10%) were on chronic AC for venous thromboembolism (n = 25), or atrial fibrillation/flutter (n = 13). The most common malignancies were cervical (n = 15) and inoperable uterine (n = 11). Implants were intracavitary (n = 14), interstitial (n = 6), or hybrid (n = 12) with a median (range) of 2 (1-3) implants, 4 (2-5) fractions, and 2 (1-3) days of bedrest per implant. 63% (n = 20) had an epidural for analgesia. AC was held for a median 3 days in 94% (n = 30) prior to the operative implant, and pharmacologic DVT prophylaxis was used in 78% (n = 25). There were two grade ≥ 2 hemorrhagic events and no new embolic events. The rate of bleeding and embolic events was acceptable, and women on chronic AC should not be excluded from potentially lifesaving operative brachytherapy, including complex cases that require spinal analgesia and interstitial applicators.