Minimize Bleeding Risk Research Articles

Ketorolac as an Analgesic Agent for Infants and Children After Cardiac Surgery

Ketorolac has been used safely as an analgesic agent for children following cardiac surgery in selected populations. Controversy exists among institutions about the risks involved with this medication in this patient group. This article reviews the current literature regarding the safety of ketorolac for postoperative pain management in children after cardiac surgery. Specifically, concerns about renal dysfunction and increased bleeding risk are addressed. Additionally, the article details pharmacokinetics and potential benefits of ketorolac, such as its opioid-sparing effect. The literature reflects that the use of this medication is not well studied in certain pediatric cardiac patients such as neonates and those with single-ventricle physiology, and the safety of this medication in regards to these special populations is reviewed. In conclusion, ketorolac can be used in specific pediatric patients after cardiac surgery with minimal risk of bleeding or renal dysfunction with appropriate dosing and duration of use.

Ketorolac as an Analgesic Agent for Infants and Children After Cardiac Surgery

Ketorolac has been used safely as an analgesic agent for children following cardiac surgery in selected populations. Controversy exists among institutions about the risks involved with this medication in this patient group. This article reviews the current literature regarding the safety of ketorolac for postoperative pain management in children after cardiac surgery. Specifically, concerns about renal dysfunction and increased bleeding risk are addressed. Additionally, the article details pharmacokinetics and potential benefits of ketorolac, such as its opioidsparing effect. The literature reflects that the use of this medication is not well studied in certain pediatric cardiac patients such as neonates and those with single-ventricle physiology, and the safety of this medication in regards to these special populations is reviewed. In conclusion, ketorolac can be used in specific pediatric patients after cardiac surgery with minimal risk of bleeding or renal dysfunction with appropriate dosing and duration of use.

Rivaroxaban and Hemostasis in Emergency Care

Rivaroxaban is an oral, direct Factor Xa inhibitor, approved for the prevention and treatment of several thromboembolic disorders. Rivaroxaban does not require routine coagulation monitoring and has a short half-life. However, confirmation of rivaroxaban levels may be required in circumstances such as life-threatening bleeding or perioperative management. Here, we explore the management strategies in patients receiving rivaroxaban who have a bleeding emergency or require emergency surgery. Rivaroxaban plasma concentrations can be assessed quantitatively using anti-Factor Xa chromogenic assays, or qualitatively using prothrombin time assays (using rivaroxaban-sensitive reagents). In patients receiving long-term rivaroxaban therapy who require elective surgery, discontinuation of rivaroxaban 20–30 hours beforehand is normally sufficient to minimize bleeding risk. For emergency surgery, we advise against prophylactic use of hemostatic blood products, even with high rivaroxaban concentrations. Temporary rivaroxaban discontinuation is recommended if minor bleeding occurs; for severe bleeding, rivaroxaban withdrawal may be necessary, along with compression or appropriate surgical treatment. Supportive measures such as blood product administration might be beneficial. Life-threatening bleeding demands comprehensive hemostasis management, including potential use of agents such as prothrombin complex concentrate. Patients taking rivaroxaban who require emergency care for bleeding or surgery can be managed using established protocols and individualized assessment.

Bridging Efforts to Longitudinally Improve and Evaluate VEnous thromboembolism prophylaxis uptake in hospitalized cancer patients through Interprofessional Teamwork (BELIEVE IT): A study by Princess Margaret Cancer Centre

Despite demonstrable risk of venous thromboembolism (VTE), thromboprophylaxis continues to be underutilized in hospitalized cancer patients. Our study evaluated institutional VTE prophylaxis rates after devising a series of strategic interventions to longitudinally improve adherence rates over a period of eight years. Between 2004 and 2012, a series of interventions were implemented to improve the thromboprophylaxis rate among patients with solid tumours hospitalized at our institution using quality improvement methodology. Interventions included development of guidelines and institutional policies coupled with educational in-services for physicians, nurses and pharmacists and engagement of the Cancer Quality Committee. Thromboprophylaxis rates were monitored to assess response to interventions. At the outset in 2004, 11 of 57 (19.3%) eligible patients received appropriate pharmacological prophylaxis and formed the baseline of our analysis. Post-2009 policy implementation and educational sessions, 46.5% of an eligible 185 inpatients were administered thromboprophylaxis. Following a two-year grace period to allow for policy acceptance, three audits were conducted in 2011 for which an average prophylaxis rate of 62.3% resulted. In 2012, following another round of educational sessions, a 96.7% rate was achieved and maintained ten weeks later. Minimal bleeding risk was observed during this eight year initiative. A reproducible 96.7% prophylaxis uptake rate was the result of our perseverance and persistence in believing that culture change was inevitable through continuously collaborating with stakeholders at all levels.

Ultrasound Endoscopic Bone Cutting for Rapid Maxillary Expansion

This study evaluated the feasibility and morbidity of ultrasound endoscopic rapid maxillary expansion. Thirteen consecutive patients (7 women and 6 men; mean age at time of surgery, 22 yr 10 months; range, 15 yr 4 months to 26 yr 3 months) who required surgically assisted rapid palatal expansion were included in this study. Eight patients had Class III malocclusion and 5 had Class II malocclusion. All osteotomies were performed using ultrasound bone-cutting instruments under direct visualization with a rigid 30° 2.7-mm-diameter endoscope connected to a video system, with access through 3 small vertical incisions. Satisfactory maxillary expansion was achieved in all patients, with minimal postsurgical sequelae. The average operative time for the 13 cases was 74 minutes (standard deviation, 11 minutes) and was not dependent on the quality of bone. Postoperative pain was measured using a visual analog scale ranging from 0 to 10 and was found to be 1.5 ± 0.8 on the first postoperative day, which decreased to 0.9 ± 0.4 on the second day. Mucosal healing was excellent and none of the patients had excessive edema, hematoma formation, or nerve injury. The procedure described is minimally invasive and has advantages over the usual technique in providing direct vision, creation of a precise and safe osteotomy, minimal bleeding risk, and decreased dissection.

Efficacy and safety of tenecteplase in pulmonary embolism

Pulmonary embolism (PE) is a relatively common life-threatening cardiovascular condition associated with significant morbidity and mortality. We present the efficacy and safety data of weight-adjusted tenecteplase in 30 consecutive patients of acute PE. 30 patients (22 male, 8 female) with acute PE were included in the study and divided into three groups: (1) Acute PE complicated by shock stage and/or persistent hypotension (12 patients). (2) RV dilatation and/or dysfunction without hypotension (14 patients). (3) Severe hypoxemia without hypotension and RV dysfunction (4 patients). Predominant symptoms were dyspnoea, cough, chest pain, syncope and haemoptysis, noted in 100% (30), 40% (12), 54% (16), 32% (9) and 10% (3) of patients respectively. RV dilatation and dyskinesia were present in 86%, septal paradoxical movement in 73% and inferior venacava collapse absent in 53% of patients respectively. 12 patients presented with acute PE and cardiogenic shock, 14 patients showed RV dilatation and dysfunction with systolic BP >90 mmHg and four patients were having RV dilation without dysfunction but severe hypoxemia. There was significant reduction in right ventricular systolic pressure and improvement in right ventricular dysfunction. Our study shows that tenecteplase is very effective and safe in the treatment of PE with minimal risk of bleeding in high risk group and intermediate risk and even in selective low risk category group of patients. However, in view of small number of patients in study group, a large multicentre randomized study would be required to draw a firm conclusion regarding the thrombolysis in low risk category patient.

Ultrasound-Assisted Thrombolysis in Submassive and Massive Pulmonary Embolism: Assessment of Lung Obstruction Before and After Catheter-Directed Therapy

New treatment guidelines support the use of catheter-directed therapy for both massive and submassive pulmonary embolism (PE). This study examines the safety and effectiveness of ultrasound-accelerated (UA) thrombolysis, for which prompt treatment is warranted to rapidly resolve thrombus and restore cardiopulmonary function. We retrospectively reviewed ten consecutive, acute submassive/massive PE patients. All patients exhibited acute symptoms and computed tomography evidence of large thrombus burden and evidence of right-ventricular (RV) dysfunction and/or failure. Patients were followed-up with posttreatment echocardiography (n = 7) and CT (n = 9) to evaluate right heart dysfunction and thrombus burden, respectively. Thrombolytic treatment was performed in all patients using the EkoSonic Endovascular system. Clinical outcomes and complications, RV pressures, and thrombus removal were evaluated. Paired Wilcoxon signed-rank tests were performed to analyze the pretreatment and posttreatment measures; p < 0.05 was considered significant. Median thrombolytic dose was 18.0 mg tissue plasminogen activator infused over 20.8 h. There was a significant decrease in pretreatment and posttreatment RV pressures (52.0-30.0; p < 0.01); there was a significant decrease in pretreatment and posttreatment Mastora obstructive indices (74-43; p < 0.01). All patients improved clinically shortly after treatment onset. All ten patients survived to discharge with a median intensive care (ICU) stay of 4 days and 14 hospital days. UA thrombolysis is promising in massive and submassive PE treatment and shows safe results. Patients showed improved thrombus burden, and rapid improvement in right cardiac function, whereas minimizing bleeding risk and ICU time were minimized. This results of this study provide the foundation for future comparative studies in treatment of large PEs.

Abstract 496: Large Pulmonary Embolism Treated with a Novel Percuatneous Catheter-Directed, Ultrasound-Assisted Low Dose Thrombolysis

Background Massive Pulmonary embolism (PE) is a life threatening diagnosis. Survival is dependent on the timing and availability of intravenous alteplase. In those who survive; recurrent PE, pulmonary hypertension and cor pulmonale are the long term sequelae. Case We describe a 63 year old morbidly obese male (weight 470 lbs) presenting with increasing dyspnea. A CT scan of the chest revealed massive clots in bilateral pulmonary arteries and right ventricular (RV) strain. Approximately 6 months prior to presentation he was diagnosed to have PE and was treated with warfarin. Warfarin was discontinued after 6 months as he was asymptomatic and CT scan showed resolution of clots. In the past few weeks he started to smoke and also complained of black stools. Due to high risk presentation, history of melena in the recent past and dyspnea at rest, he was offered percutaneous therapy for PE. Using single internal jugular venous approach, right heart catherterization and pulmonary angiography was performed. Bilaterally ultrasound assisted- thrombolysis infusion catheters were placed in the pulmonary arteries. Alteplase was infused at low dose; total dose infused was 24 mg over 19 hours (Typical intravenous dose is 100 mg). Baseline hemodynamics showed severe pulmonary hypertension. Follow up angiogram showed almost complete resolution of clots and complete improvement in symptoms. Work up revealed Anti-Thrombin III deficiency. He was treated bivalirudin and discharged on warfarin. Follow-up testing showed improved RV pressures. Discussion The mortality rate for acute PE is 2-6% in those with hemodynamic stability, and 30% or more in those with shock or unstable hemodynamics. Catheter-directed local thrombolysis should be considered as a therapy in those with sub-massive and massive PE with the advantage of significantly lower thrombolytic dose (almost 75% lower) with minimal bleeding risk. The ultrasound energy in this thrombolytic EKOS @ catheter helps loosen the clot via mechaincal energy, allowing lower dose of thrombolytics to be used locally. Ongoing studies utilizing this technology such as SEATTLE-II and ULTIMA will offer further evidence based guidelines to manage acute pulmonary embolism.

Prasugrel

Antiplatelet drugs are the cornerstone of treatment for patiens with Acute Coronary Syndromes (ACS) undergoing percutaneous coronary intervention. Clopidogrel and aspirin improve longterm vascular clinical outcomes in these patients and have become a standard of care. However, many patients still experience ischemic/thrombotic events due to potential insufficient platelet inhibition. Prasugrel is a novel third-generation oral thienopyridine analog with a structure similar to that of clopidogrel and ticlopidine. Like the other thienopyridines, prasugrel is a pro-drug requiring hepatic metabolism to its active form to inhibit platelet aggregation induced by Adenosine Diphosphate (ADP) by irreversibly binding to the ADP purinergic receptor (P2Y12) on the platelet surface. Laboratory results with prasugrel support more potent antiplatelet effects, a lower interpatient variability in antiplatelet response, and a reduced time to onset of antiplatelet activity compared with clopidogrel, even when clopidogrel is administered at doses higher than the currently approved 300-mg loading dose and 75-mg/day maintenance dose. These differences may have mainly a pharmacokinetic basis.While the active metabolites of prasugrel and clopidogrel show similar levels of platelet inhibitioninvitro, theamount of eachactivemetabolite generatedinvivomaybequite different, expecially in some substet of patients (e.g., the so called ‘‘CYP2C9 poor metabolizers’’). However, it is not yet clear whether these pharmacologic improvements can translate to clinical benefits. The results of the large TRITON-TIMI 38 trial, which compared prasugrel and clopidogrel in patients with acute coronary syndrome who were scheduled to receive coronary stents, demonstrated a significant reduction in ischemic events with prasugrel, although this was associated with a greater risk of bleeding. More studies with prasugrel should determine its optimal dosage regimen to minimize bleeding risks and evaluate its outcomes in ACS in varius subset of patiens. The exact role of prasugrel in the management of coronary heart disease remains to be defined.

Ticagrelor

Antiplatelet drugs are the cornerstone of treatment for patients with acute coronary syndromes (ACS) who undergo percutaneous coronary intervention. Clopidogrel and aspirin improve long-term clinical outcomes in these patients and have become a standard of care. However, many patients still experience ischemic/thrombotic events, and it appears that insufficient response to both aspirin and clopidogrel contribute to this failure. Clopidogrel is a prodrug that is metabolized in the liver to its active form. It inhibits platelet aggregation induced by adenosine diphosphate (ADP) by irreversibly binding to the ADP purinergic receptor (P2Y12) on the platelet surface. Prasugrel, a novel thienopyridine, exhibits more potent antiplatelet effects with lower interpatient variability and more rapid onsetof activity. All thienopyridines, however, have pharmacological limitations, which have fueled the search for more effective non-thienopyridine P2Y12 inhibitors. Promising results have been reported with ticagrelor, the first oral P2Y12 receptor antagonist with reversible effects. Ticagrelor does not require metabolic activation. In vivo one active metabolite is formed whose potency and pharmacokinetic properties are very similar to those of the parent compound, but it probably plays a minor role in ticagrelor’s antiplatelet effects. Ticagrelor offers more rapid and more pronounced platelet inhibition than other antiplatelet agents. Furthermore, the reversibility of its effects may allow shorter periods of suspension of antiplatelet treatment prior to surgery, reducing the risk of perioperative thrombotic and hemorrhagic events. Preliminary results show a trend toward protection from coronary events and no increased risk for major bleeding compared with clopidogrel. Further investigation is needed, however, to determine the optimal dosage for minimizing bleeding risks and to evaluate its impact on outcomes in various subsets of ACS patients.

Abstract TP424: Timing Of Deep Vein Thrombosis Formation After Aneurysmal Subarachnoid Hemorrhage

Background: Deep vein thrombosis (DVT) is a common complication following aneurysmal subarachnoid hemorrhage (aSAH). The time period of greatest risk of developing DVT after aSAH is not known. Early DVT detection may enable earlier treatment and prevent progression to symptomatic DVT or pulmonary embolism (PE). We tested the hypothesis that DVT most often occurs during the period of highest risk of delayed cerebral ischemia (3-14 days post-rupture). Methods: We performed a retrospective review of 154 patients admitted to the OHSU NeuroICU with aSAH between April 2008 and April 2010. 121 patients received periodic screening lower extremity ultrasounds, typically twice weekly, and prophylaxis with sequential compression devices (SCDs) but no chemoprophylaxis such as heparin. The remaining 33 patients did not receive screening studies due to withdrawal of care or attending physician preference. Results: 26 of 121 patients (21.5%) who received ultrasound screening developed DVT after aneurysm rupture. 3 of 26 patients (2.5% of the total screened population) had symptomatic DVTs, as defined by documented clinical suspicion in chart notes, and 1 of these developed PE. DVTs were significantly more likely to be detected 3-14 days post-bleed (χ-square, p &lt; 0.0006) and were detected on average 12.0 +/- 6.8 days (median 10 days) after aneurysm rupture. Because DVTs did not necessarily occur on the day of detection, we calculated the period at risk by determining the day of the last known ultrasound without DVT, or by the day of aneurysm rupture if the DVT was detected on the first screening scan. The average day beginning the period at risk was 5.7 +/- 6.7 days (median 2 days) after aneurysm rupture. The average number of days within the period of risk was 6.3 +/- 3.6 days (median 6.5 days). Conclusion: DVTs are significantly more likely to be detected 3-14 days after aneurysm rupture. Repeated screening allows for evaluation of the period of highest risk for developing DVT. The data suggest that this period occurs between 5.7 and 12.0 days on average (median 2-10 days) following aneurysm rupture. Prospective studies are needed to determine whether chemoprophylaxis targeted to this time window reduces DVT incidence while minimizing bleeding risk.

How to Manage Antiplatelet Therapy for Stenting in a Patient Requiring Oral Anticoagulants

The optimal antiplatelet regimen for patients on oral anticoagulants undergoing coronary stenting continues to be controversial. It is not an insignificant problem, as 5-7% of patients undergoing stenting are on oral anticoagulation for atrial fibrillation, a prosthetic valve, a recent left ventricular thrombus and recent pulmonary embolus. When given in combination with dual antiplatelet therapy, major bleeding is significantly increased, which is associated with an increased mortality. The balance between a reduction in stroke, stent thrombosis and myocardial infarction without a significant increase in major bleeding requires choosing therapy based upon the estimation of the risks of each adverse event. In patients with a low risk of stroke, such as those with atrial fibrillation and a CHADS(2) score of 0-1, dual antiplatelet therapy alone is sufficient. In those at moderate to high risk of stroke, dose-adjusted oral anticoagulation is needed. In those with the highest bleeding risk, use of a bare metal stent is strongly advised. In addition to bare metal stent use, the use of proton pump inhibitors, tight control of the international normalized ratio (INR) and only one month of dual antiplatelet therapy can reduce the bleeding risk without an increase in stroke or stent thrombosis. When a drug eluting stent (DES) is needed, a second generation DES should be used and triple therapy continued for 6months (12months if stent thrombosis risk is very high), followed by a single antiplatelet therapy and an oral anticoagulant. Since the newer antiplatelet agents and anticoagulants have not been studied in this setting, clopidogrel and warfarin should be used. Recently, the WOEST trial suggested that clopidogrel alone plus an oral anticoagulant resulted in an equal outcome with a significantly lower bleeding risk when compared to triple therapy. If confirmed, this regimen may become the standard of care. Presently, however, limiting the duration of triple therapy followed by clopidogrel and an oral anticoagulant seems the best option for the majority of patients to minimize bleeding risk without an increase in other adverse events.

Argatroban Dose Reductions for Suspected Heparin-Induced Thrombocytopenia Complicated by Child-Pugh Class C Liver Disease

To report our experience of reduced-dose argatroban in a patient with suspected heparin-induced thrombocytopenia (HIT) and Child-Pugh class C liver disease and review the relevant literature to summarize current recommendations on argatroban use in patients with severe liver disease. A 58-year-old male with Child-Pugh class C liver disease (Model for End-Stage Liver Disease [MELD] score = 31, total bilirubin 4.5 mg/dL) and hemodialysis-dependent renal failure was hospitalized with acute deep vein thrombosis (DVT). Three days after heparin initiation for DVT, he developed thrombocytopenia. Given his heparin exposure (both for treatment of DVT and ongoing hemodialysis), HIT was suspected and all heparinoids were immediately discontinued. Argatroban was initiated for the treatment of HIT while laboratory testing for HIT antibodies and the serotonin release assay were completed. Because of the patient's advanced liver disease, the starting dose of argatroban was reduced to 0.2 μg/kg/min, with frequent monitoring of the activated partial thromboplastin time (aPTT) (goal 60-85 seconds). Despite this dose reduction, the aPTT was supratherapeutic. Following further dose reductions, a final argatroban maintenance dose of 0.05 μg/kg/min was necessary for the attainment of goal aPTTs. Reducing the starting dose of argatroban to 0.5 μg/kg/min is recommended in patients with liver disease. Nevertheless, this recommended dose is largely based on data from patients with more moderate liver disease (eg, Child-Pugh class A or B), and dosing in more advanced liver disease remains largely unexplored. Patients with more advanced liver disease may require additional dose reductions to avoid supratherapeutic concentrations of anticoagulation agents and to minimize bleeding risk. This report illustrates the importance of careful selection of argatroban dosing and appropriate aPTT monitoring in patients with severe liver disease. Excessive anticoagulation may precipitate major bleeding complications, placing patients with this complicated disease at undue risk.

Bleeding Risk during Treatment of Acute Thrombotic Events with Subcutaneous LMWH Compared to Intravenous Unfractionated Heparin; A Systematic Review

BackgroundLow Molecular Weight Heparins (LMWH) are at least as effective antithrombotic drugs as Unfractionated Heparin (UFH). However, it is still unclear whether the safety profiles of LMWH and UFH differ. We performed a systematic review to compare the bleeding risk of fixed dose subcutaneous LMWH and adjusted dose UFH for treatment of venous thromboembolism (VTE) or acute coronary syndromes (ACS). Major bleeding was the primary end point.MethodsElectronic databases (MEDLINE, EMBASE, and the Cochrane Library) were searched up to May 2010 with no language restrictions. Randomized controlled trials in which subcutaneous LMWH were compared to intravenous UFH for the treatment of acute thrombotic events were selected. Two reviewers independently screened studies and extracted data on study design, study quality, incidence of major bleeding, patients’ characteristics, type, dose and number of daily administrations of LMWH, co-treatments, study end points and efficacy outcome. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated using the random effects model.ResultsTwenty-seven studies were included. A total of 14,002 patients received UFH and 14,635 patients LMWH. Overall, no difference in major bleeding was observed between LMWH patients and UFH (OR = 0.79, 95% CI 0.60–1.04). In patients with VTE LMWH appeared safer than UFH, (OR = 0.68, 95% CI 0.47–1.00).ConclusionThe results of our systematic review suggest that the use of LMWH in the treatment of VTE might be associated with a reduction in major bleeding compared with UFH. The choice of which heparin to use to minimize bleeding risk must be based on the single patient, taking into account the bleeding profile of different heparins in different settings.

Abstract 2188: Bleeding Events and Anticoagulant Discontinuation in Patients with Atrial Fibrillation

BACKGROUND: Annually, about 2.3% of patients receiving warfarin prophylaxis experience major bleeding. Discontinuation of warfarin due to hemorrhage can leave patients unprotected against potential stroke. OBJECTIVE: To assess the rate of warfarin discontinuation and identify factors associated with warfarin discontinuation among patients with atrial fibrillation (AF). METHODS: Retrospective cohort study was conducted using the Market Scan Database between1/12005 and 6/30/2008. Study patients were ≥18 years old with ≥2 AF diagnoses where at least one diagnosis was prior to the first warfarin prescription (index). An additional warfarin prescription within 6-months after index date was required to ensure continuous treatment. Patients were excluded if they had previous warfarin treatment or a cardioversion during one year history period. Continuous health benefit coverage was required during study period. Patients were followed until a hemorrhagic event, warfarin discontinuation, or end of study period. Discontinuation was defined by ≥90 days without a refill after depletion of the drug supply from the prior prescription claim. Recent hemorrhage was defined as hemorrhage within 90 days before discontinuation. Multiple regression analyses were conducted to identify the factors associated with warfarin discontinuation. RESULTS: 7,971 patients met study eligibility criteria. Mean (±SD) patient age was 67.8 (±12.7), with majority ≥65 years old (59.3%). 41.2% were female. During follow-up, 51.7% of patients discontinued warfarin (p&lt;.001). A higher proportion of patients who had a recent hemorrhage (61.8%) discontinued warfarin compared to those without (51.3%). After adjustment, patients with a recent hemorrhage were 35% more likely to discontinue warfarin, compared to those without (RR=1.35; CI:1.16-1.58). Age of ≥85 (reference: &lt;65), and history of ≥1 hospitalization or emergency room visit were associated with increased likelihood of discontinuation (all p&lt;.001). Female, daily doses&gt;5mg (reference: ≤5mg), concomitant use of gastroprotective agents, and CHADS2 scores ≥1 were associated with decreased likelihood of discontinuation (all p&lt;.05). CONCLUSIONS: In this retrospective cohort, half of AF patients receiving warfarin discontinued their treatment. A recent hemorrhage was associated with an increase in discontinuation. A novel therapy with a predictable profile may help minimize bleeding risk and treatment discontinuation.

Bleeding and Acute Coronary Syndromes: Defining, Predicting, and Managing Risk and Outcomes

Acute coronary syndromes (ACS) continue to have a large impact on morbidity and mortality in the United States. Over the last two decades, there have been several advancements in the care of patients with ACS. The use of combined antiplatelet and anticoagulants and early invasive risk stratification in high risk patients has improved the rates of major adverse cardiovascular events. However, this treatment strategy increases the risk for bleeding. Studies have found an association between bleeding and subsequent mortality and morbidity in ACS patients; therefore, minimizing bleeding risk has become a priority. This review describes the prevalence of bleeding during ACS management, risk for bleeding, and strategies to reduce bleeding risk.

Management of Symptomatic Ascites in Hospice Patients With Paracentesis

Refractory ascites causes significant distress to patients and can be managed in various ways. In hospice patients where the goal of care is to preserve comfort and foster better quality of life, diuretics should be tried first; however, in resistant cases, home-based paracentesis should be entertained. Home-based paracentesis is a safe and simple procedure that can be done blindly, if done under standard precautions there is minimal associated risk of bleeding, infection or perforation and no need for pre or post-laboratory testing or the correction of high international normalization ratio or thrombocytopenia. Home-based paracentesis is cost effective, provides immediate symptomatic relief, good patient and caregiver satisfaction and obviates the associated distress to the patient and family of transporting the patient for either outpatient or inpatient paracentesis.

New oral anticoagulant drugs

Thromboembolic disease (TED) is the leading cause of morbidity and mortality worldwide. The hallmark of oral long-term anticoagulant therapy has been the use of vitamin K antagonists, whose anticoagulant effect is exerted inhibiting vitamin K epoxide reductase. Warfarin and acenocoumarol are the most commonly used. In the last five years several new drugs for long term anticoagulation have been developed, which can inhibit single clotting factors with the purpose of improving drug therapeutic range and, ideally, minimizing bleeding risks. This review addresses the state of the art on the clinical use of inhibitors of activated factor X and thrombin.

Nuevos anticoagulantes orales

Thromboembolic disease (TED) is the leading cause of morbidity and mortality worldwide. The hallmark of oral long-term anticoagulant therapy has been the use of vitamin K antagonists, whose anticoagulant effect is exerted inhibiting vitamin K epoxide reductase. Warfarin and acenocoumarol are the most commonly used. In the last five years several new drugs for long term anticoagulation have been developed, which can inhibit single clotting factors with the purpose of improving drug therapeutic range and, ideally, minimizing bleeding risks. This review addresses the state of the art on the clinical use of inhibitors of activated factor X and thrombin.

Venous Thromboembolism, Bleeding, and Venous Thromboembolism Prophylaxis Rates for Wounded Soldiers Hospitalized at the Walter Reed Army Medical Center

PURPOSE: Soldiers with traumatic injuries are at increased risk for venous thromboembolism (VTE). Complicated injury patterns and repeat trips to the operating room make prophylaxis difficult, and the optimal method for preventing VTE while minimizing bleeding risk is unknown.