Pharmacologic Anticoagulation Research Articles

Safety of abdominal paracentesis in hospitalised patients receiving uninterrupted therapeutic or prophylactic anticoagulants.

Abdominal paracentesis is a frequently performed procedure in hospitalised patients with ascites. Concurrently, most hospitalised adult patients receive pharmacologic anticoagulation, either for therapeutic purposes or prophylactically to prevent venous thromboembolism. Despite this, minimal evidence exists to guide management of anticoagulant therapy pre- and post-paracentesis. The authors aimed to investigate the safety of abdominal paracentesis in hospitalised patients receiving therapeutic or prophylactic anticoagulation, including in patients for whom these medications were withheld periprocedurally. TriNetX, an electronic health record data set, was queried to identify patients between the ages of 18 and 80 years who received an abdominal paracentesis while hospitalised at the authors' institution between September 2017 and June 2022. Patients receiving prophylactic anticoagulation (137), therapeutic anticoagulation (74) and no anticoagulation because of coagulopathy or thrombocytopenia (15) were compared. Rates of withholding anticoagulation, performing service, pre- and post-paracentesis haemoglobin, bleeding complications, thrombotic complications and need for red blood cell transfusion were analysed. Procedure-related bleeding complications occurred in two (1.4%) patients in the prophylactic group and 0 (0%) patients in the therapeutic group (P = 0.54). No thrombotic complications occurred. Rates of red blood cell transfusions post-paracentesis were similar between groups. Analysis of secondary end-points identified significant differences in rates of withholding anticoagulation and mean change in haemoglobin between performing services. Performance of abdominal paracentesis in patients receiving therapeutic or prophylactic anticoagulation appears to be safe regardless of whether anticoagulation was interrupted periprocedurally, with low rates of bleeding complications, thrombotic complications or need for red blood cell transfusions post-paracentesis.

Pharmacologic Anticoagulation Is Associated With a Lower Risk of Recurrent Venous Thromboembolic Events During Janus Kinase Inhibitor Use for Patients With a Prior Thrombosis.

Janus kinase (JAK) inhibitors tofacitinib and upadacitinib are effective therapies for inflammatory bowel disease and rheumatologic disorders but currently possess a warning for increased venous thromboembolism (VTE) risk. Some patients with a history of VTE may benefit from a JAK inhibitor, but the risk of recurrent VTE with JAK inhibitor use is unclear. Our goal was to observe rates of new VTE events after starting JAK inhibitor therapy in patients with a prior VTE, and observe whether concurrent anticoagulation (AC) reduces this risk. We conducted a review of adults prescribed tofacitinib or upadacitinib between January 1, 2000, and June 30, 2023, with a prior history of VTE. Patient charts were reviewed for demographic data, disease type, and VTE date(s), and to verify duration of JAK inhibitor use along with any concurrent AC. VTEs following JAK inhibitor initiation were identified by International Classification of Diseases-Tenth Revision code and verified by physician documentation and imaging. We identified 79 patients with a documented VTE history before initiating JAK inhibitors, 47 of whom began a JAK inhibitor with concurrent AC. Of these, 15 patients discontinued AC while receiving JAK inhibitors. In total, 5 new VTE events were observed during 55.42 patient-years of JAK inhibitor treatment without concurrent AC (9.0 events per 100 patient-years), while no new VTE events occurred during 65.2 patient-years of JAK inhibitor treatment with concurrent AC, demonstrating a lower risk of recurrent VTE (P = .020). These results suggest that for patients with a prior VTE history there is a high risk for recurrent VTE while receiving JAK inhibitors. Concurrent use of AC with JAK inhibitors appears to be protective against recurrent VTEs in this population.

The impact of perioperative pharmacologic anticoagulation on venous thromboembolism and bleeding complications following surgery for pelvic organ prolapse

The impact of perioperative pharmacologic anticoagulation on venous thromboembolism and bleeding complications following surgery for pelvic organ prolapse

Direct thrombin inhibiting coating for active coagulant management in extracorporeal circulation

Existing anticoagulant coatings are designed to inhibit the initial attachment of coagulant factors, but they frequently suffer from undesirable coating defects that result in a declined physical barrier function. Heparin, serving as a commercialized pharmacological coating via the activation of antithrombin, frequently causes heparin-induced thrombocytopenia. Here, we developed an argatroban-polyphenol conjugate proteinaceous coating (named PDA-BSA-AG coating) that actively inhibits thrombin, in contrast to previously reported passive coatings and indirect pharmacological anticoagulants. Following clinical treatment standards, a magnetic levitation ventricular assist system was employed for the first time to accomplish extracorporeal circulation utilizing PDA-BSA-AG coated tubes. The results show that the clotting time of the PDA-BSA-AG coating was 68.9 % longer than that of clinical Bioline heparin coating. It is noteworthy that argatroban not only delivers anticoagulant effectiveness but also enhances patient safety and reduces the occurrence of complications. A novel combination of the primary specific proteins of platelets and the coagulation-inflammatory cascade reaction of the cytokines and complement systems explained the anticoagulation mechanism. Reliable biocompatibility (hemolysis, cytotoxicity, and antibacterial activity) was noted, along with impressive coating stability for up to 6 h of extracorporeal circulation. These results above suggested that the PDA-BSA-AG coating is promising for a wide range of blood-contacting devices.

Prophylactic anticoagulation after minimally invasive hysterectomy for endometrial cancer: a cost-effectiveness analysis

ObjectiveTo determine our institutional rate of venous thromboembolism (VTE) following minimally invasive surgery for endometrial cancer and to perform a cost-effectiveness analysis of extended prophylactic anticoagulation after minimally invasive staging...

Factor XII promotes the thromboinflammatory response in a rat model of venoarterial extracorporeal membrane oxygenation

BackgroundFactor XII (FXII) is a multifunctional protease capable of activating thrombotic and inflammatory pathways. FXII has been linked to thrombosis in extracorporeal membrane oxygenation (ECMO), but the role of FXII in ECMO-induced inflammatory complications has not been studied. We used novel gene-targeted FXII- deficient rats to evaluate the role of FXII in ECMO-induced thromboinflammation. MethodsFXII-deficient (FXII−/−) Sprague–Dawley rats were generated using CRISPR/Cas9. A minimally invasive venoarterial (VA) ECMO model was used to compare wild-type (WT) and FXII−/− rats in 2 separate experimental cohorts: rats placed on ECMO without pharmacologic anticoagulation and rats anticoagulated with argatroban. Rats were maintained on ECMO for 1 hour or until circuit failure occurred. Comparisons were made with unchallenged rats and rats that underwent a sham surgical procedure without ECMO. ResultsFXII−/− rats were maintained on ECMO without pharmacologic anticoagulation with low resistance throughout the 1-hour experiment. In contrast, WT rats placed on ECMO without anticoagulation developed thrombotic circuit failure within 10 minutes. Argatroban provided a means to maintain WT and FXII−/− rats on ECMO for the 1-hour time frame without thrombotic complications. Analyses of these rats demonstrated that ECMO resulted in increased neutrophil migration into the liver that was significantly blunted by FXII deficiency. ECMO also resulted in increases in high molecular weight kininogen cleavage and complement activation that were abrogated by genetic deletion of FXII. ConclusionsFXII initiates hemostatic system activation and key inflammatory sequelae in ECMO, suggesting that therapies targeting FXII could limit both thromboembolism and inopportune inflammatory complications in this setting.

Robust coagulation activation and coagulopathy in mice with experimental acetaminophen-induced liver failure

BackgroundPatients with acetaminophen (APAP)-induced acute liver failure (ALF) display both hyper- and hypocoagulable changes not necessarily recapitulated by standard hepatotoxic doses of APAP used in mice (eg, 300 mg/kg). ObjectivesWe sought to examine coagulation activation in vivo and plasma coagulation potential ex vivo in experimental settings of APAP-induced hepatotoxicity and repair (300-450 mg/kg) and APAP-induced ALF (600 mg/kg) in mice. ResultsAPAP-induced ALF was associated with increased plasma thrombin–antithrombin complexes, decreased plasma prothrombin, and a dramatic reduction in plasma fibrinogen compared with lower APAP doses. Hepatic fibrin(ogen) deposits increased independent of APAP dose, whereas plasma fibrin(ogen) degradation products markedly increased in mice with experimental ALF. Early pharmacologic anticoagulation (+2 hours after 600 mg/kg APAP) limited coagulation activation and reduced hepatic necrosis. The marked coagulation activation evident in mice with APAP-induced ALF was associated with a coagulopathy detectable ex vivo in plasma. Specifically, prolongation of the prothrombin time and inhibition of tissue factor–initiated clot formation were evident even after restoration of physiological fibrinogen concentrations. Plasma endogenous thrombin potential was similarly reduced at all APAP doses. Interestingly, in the presence of ample fibrinogen, ∼10 times more thrombin was required to clot plasma from mice with APAP-induced ALF compared with plasma from mice with simple hepatotoxicity. ConclusionThe results indicate that robust pathologic coagulation cascade activation in vivo and suppressed coagulation ex vivo are evident in mice with APAP-induced ALF. This unique experimental setting may fill an unmet need as a model to uncover mechanistic aspects of the complex coagulopathy of ALF.

Current Trends Regarding Perioperative Pharmacological Anticoagulation in Lower Limb Surgeries among Orthopedic Surgeons of Pakistan -An Audit

Abstract:Perioperative anticoagulation has been recommended by AAOS, AACP, and ASH during orthopedic procedures of the lower limb. Guidelines show a difference of opinion regarding the optimum duration and drug of choice giving a way to use different methods of anticoagulation. This audit assessed the preferences for pharmacological anticoagulation in lower limb surgeries among orthopedic surgeons of Pakistan. Materials and Methods: An online questionnaire-based cross-sectional study was started from June-September 2021 in Dr Ruth K.M. Pfau Civil Hospital Karachi where Orthopedic surgeons (n=632) were invited to fill those questionnaires. A total of 85 orthopedic surgeons responded completely. An electronic eight-question survey was designed which included questions about demographics of surgeons, the drug of choice, perioperative duration, preferred surgeries, and average incidence of thromboembolism per year. Results: 12.9% surgeons use anticoagulation for all surgeries while 82.3% of orthopedic surgeons use anticoagulants in selective surgeries. LMWH (94.1%) and Rivaroxaban (17.6%) were the drug of choice for most surgeons. 70.6% of respondents never used anticoagulation preoperatively. 17.7% used it three days preoperatively. 28.24% of surgeons prescribed anticoagulation for 3 days postoperatively while 17.7% of surgeons prescribed anticoagulation for 2 weeks postoperatively. 10.6% of surgeons never used anticoagulation postoperatively. Arthroplasty (71.7%), trauma (55.3%), and pelvis and acetabulum (54.1%) were the subspecialties with routine anticoagulation. 81.2% and 17.7% of surgeons reported less than 1% and 1% to 3% incidence of thromboembolism, respectively. No surgeon reported any incidence of thromboembolism above 5%. Conclusion: Use of anticoagulation is prevalent among orthopedic surgeons in Pakistan. However, significant differences are observed regarding the perioperative duration. The surgeons need to prescribe DOAC such as Rivaroxaban and Dabigatran as agents of choice while extended postoperative pharmacological anticoagulation of 28-35 days needs to be adopted.

P93. The effect of a postoperative epidural hematoma following lumbar spinal stenosis surgery

P93. The effect of a postoperative epidural hematoma following lumbar spinal stenosis surgery

P22. Recurrent CSF leak following repair of incidental durotomy in lumbar spinal stenosis surgery

P22. Recurrent CSF leak following repair of incidental durotomy in lumbar spinal stenosis surgery

Atrial fibrillation in the elderly population: Challenges and management considerations.

ImportanceAtrial fibrillation is the most clinically significant arrhythmia in humans when viewed both from a global and also a national perspective. In the United States, approximately 2.7‐6.1 million people are estimated to have atrial fibrillation. With the aging of the population, this prevalence is on an increasing trend and remains an obstacle to cardiovascular health despite significant advancements specific to cardiovascular disease management.ObservationIn this specific group of patients, healthcare utilization is a concern from the public health perspective. Unfortunately, misconceptions dominate clinical decision making; for instance, the avoidance of safe and effective anticoagulation strategies in patients at the highest risk for embolic strokes continues to be widespread in clinical practice and is often based on a skewed assessment of risk versus benefit. Also, when there are contraindications to standard interventions for atrial fibrillation, a clear and nuanced understanding of second‐ and third‐line interventions with proven benefit is often lacking.Conclusions and RelevanceAn individualized approach should be followed by physicians when managing atrial fibrillation in the elderly patient, taking into consideration the risk of complications, particularly the embolic stroke and the availability of treatment options for stroke prevention whether through pharmacological anticoagulation or left atrial appendage occluding devices. The following review sets out to clarify these issues.

Inhibition of Platelet Aggregation After Coronary Stenting in Patients Receiving Oral Anticoagulation.

Approximately 18% of patients with atrial fibrillation undergo a percutaneous coronary intervention (PCI) to treat coronary heart disease. Pharmacological anticoagulation in patients with atrial fibrillation and PCI involves a trade-off of potential ischemic and hemorrhagic complications. This review is based on pertinent publications that were retrieved by a selective literature search, including current guidelines and recommendations. Dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and a P2Y12 inhibitor protects against stent thrombosis, but not against thromboembolic stroke. In contrast, oral anticoagulation does provide effective prevention against stroke during atrial fibrillation. Combining DAPT with oral anticoagulation (triple therapy) over the long term, as has been recommended to date, carries an elevated risk of hemorrhage. In a randomized controlled trial, 44% of patients with atrial fibrillation receiving triple therapy sustained a hemorrhagic event, compared to 19.4% of patients receiving dual therapy. A meta-analysis has shown that clinically relevant hemorrhage is less common under combined treatment with one of the new oral anticoagulants (NOAC) and a single antiplatelet drug than under triple therapy including a vitamin K antagonist (hazard ratio, 0.56; 95% confidence interval 0.39; 0.80]), but no significant difference was found with respect to stent thrombosis, myocardial infarction, or overall mortality. After coronary stent implantation, dual therapy with a NOAC and a P2Y12 inhibitor is recommended, subsequent to triple therapy given only during the peri-interventional period.

Postoperative Pharmacologic Anticoagulation following Temporal Lobe Resection of a Gliosarcoma in a Hypercoagulable Patient

Gliosarcomas are a rare subtype of glioblastomas associated with high rates of malignancy-associated venous thromboembolism (VTE). VTE risk is further increased in hypercoagulable patients upon discontinuing pharmacologic anticoagulation for surgery. We present a 60-year old obese male with history of hypercoagulability on apixaban who developed extensive thrombosis following resection of a gliosarcoma. Prior to temporal lobe resection, apixaban was discontinued and an IVC filter placed. On postoperative day 4, imaging revealed thrombosis above the IVC filter extending to the bilateral common, internal and external iliac, and femoral veins, requiring immediate anticoagulation and suction thrombectomy. Clinicians must balance the risk of VTE and intracerebral hemorrhage following neurosurgical. While withholding pharmacologic VTE is standard, hypercoagulable patients may benefit from pharmacologic prophylaxis postoperatively. Patients with multiple risk factors including malignancies with high rates VTE, like gliosarcomas, medical and hematological conditions, including idiopathic erythrocytosis, and history of VTE may benefit from earlier pharmacologic prophylaxis.

Anticoagulation in Elective Spine Cases: Rates of Hematomas Versus Thromboembolic Disease.

Retrospective cohort study with propensity matched cohorts. The purpose of this study was to evaluate the association of anticoagulation with VTE and hematoma complications after spine surgery. One of the major complications of surgery is VTE which can range in presentation. Spine surgery is an especially complex balance between minimizing the risk of a VTE event and also the increased risk of a hematoma which can lead to devastating neurological outcomes. The elective spine surgery cases at a single academic center between 2015 and 2017 were identified. A total of 3790 patients were initially identified. Two hundred sixty patients were excluded. The cohort was then matched using a propensity score. This matched a single patient who did not receive anticoagulation to a single patient who did within the institution. This left a total of 1776 patients with 888 patients in each arm. The incidence of VTE, PE, and unplanned reoperation for hematoma in this cohort was 0.96%, 0.34%, and 1.13%, respectively. Predicted odds of VTE and PE were not significantly different; however, the odds of an unplanned reoperation for hematoma (odds ratio [OR] = 7.535, 95% confidence interval [CI]: 2.004-28.340, P = 0.002) were greater for those who received pharmacological anticoagulation in our institutional cohort. In this study, anticoagulation does not lead to lower rates of VTE events, but it increases the risk of symptomatic hematomas which require a return trip to the OR. While this was not a randomized controlled trial, we attempted to correct for this with propensity matching. Future randomized control trials would be needed.Level of Evidence: 3.

Incidence, diagnosis, treatment methods, and outcomes of clinically suspected venous thromboembolic disease in patients with COVID-19 in a quaternary hospital in Brazil.

BackgroundProthrombotic states have been associated with viral infections and the novel Sars-COV-2 infection has been associated with elevated D-dimer levels, although no causal relation has been clearly established.ObjectivesThis study presents an epidemiological analysis of manifest VTE episodes in a group of patients hospitalized because of COVID-19.MethodsMedical records of patients who presented symptomatic deep vein thrombosis and/or pulmonary embolism in concomitance with confirmed COVID-19 were retrospectively studied. Demographic characteristics, prevalence of VTE, site of occurrence, D-dimer variation over time, management, and outcomes were analyzed.ResultsDuring the study period, 484 confirmed cases of COVID-19 were admitted, 64 of which displayed VTE symptoms and 13 of which had confirmed symptomatic VTE(2.68% of total sample and 20.31% of symptomatic cases). Most cases (76.92%) occurred in intensive care. On the day attributed to VTE onset, D-dimer levels were over 3,000 ng/mL in 8 (80%) patients, a significant increase from baseline admission levels (p < 0.05). A significant decrease was also observed in D-dimer values at hospital discharge (p < 0.05). All patients received pharmacological thromboprophylaxis and/or anticoagulation as indicated. Two deaths occurred during the study, both patients with severe comorbidities. At the end of our study protocol, nine patients had been discharged and two remained hospitalized, but had no signs of VTE worsening.ConclusionsVTE prevalence in hospitalized COVID-19 patients was 2.7%, and higher in intensive care units. Early institution of prophylaxis and immediate full anticoagulation when VTE is diagnosed should be the goals of those who treat this kind of patient.

Telehealth Outpatient Monitoring of a SARS-CoV-2 Familial Cluster Infection in Peru: Adapting to a Healthcare Crisis

The coronavirus disease 2019 (COVID-19) epidemic is evolving in Latin America despite implementation of government measures. We report a familial cluster in Lima, Peru, with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Two young and two middle-aged adults with a wide range of COVID-19 manifestations experienced successful management under telehealth outpatient monitoring. Telehealth monitoring was scheduled as suggested by Peruvian Ministry of Health Guidelines and was performed by a designated physician who assessed the patients and prescribed treatment. On May 14, 2020, a 25-year-old male, who worked treating COVID-19 patients, reported constitutional symptoms and tested positive for SARS-CoV-2. Clinical improvement was achieved with azithromycin and ivermectin therapy. He had been in contact with his parents (Cases 2 and 3) and his sister (Case 4). Cases 2 and 3 developed moderate pulmonary compromise requiring oxygen supplementation and pharmacological therapy, including corticosteroids and anticoagulation, under home medical assessment and telehealth monitoring. Case 4 developed mild symptoms and periorbital rash, an atypical dermatological finding. To our knowledge this represents the first report of a familial cluster with COVID-19 that was successfully managed under scheduled telehealth outpatient monitoring in Latin America.

Passive ankle motion and calf massage without anticoagulation therapy after total hip arthroplasty: A retrospective study

BackgroundIt has been previously reported that manual calf massage and passive ankle motion after total hip arthroplasty could reduce the incidence of venous thromboembolism. However, a combination of chemical and mechanical prophylaxes was employed. In this study, we aimed to examine the effect of mechanical prevention without pharmacological antithrombotic intervention. MethodsOf the 313 patients who underwent unilateral primary total hip arthroplasty and received passive ankle motion and calf massage postoperatively at our hospital between January 2015 and December 2019, 261 (58 men, 203 women; mean age 62.1 years) were included in this retrospective study. Pharmacological anticoagulation therapy was administered in 176 patients (combination group); 137 patients only underwent calf massage and passive ankle motion without anticoagulation therapy (single group). The study outcomes were operation time, the incidence of deep vein thrombosis, pulmonary thromboembolism, intraoperative bleeding, estimated actual blood loss, blood transfusion, and major bleeding. ResultsNo significant differences were found in sex, age, side, platelet counts, activated partial thromboplastin time, prothrombin time, prothrombin time - International Normalized Ratio, intraoperative blood loss, estimated blood loss, and operation time. Moreover, the incidence of deep vein thrombosis, pulmonary thromboembolism, and intraoperative bleeding was not significantly different between the groups (deep vein thrombosis 4.0% vs. 6.3%, p = 0.244; pulmonary thromboembolism 0.7% vs. 0%, p = 0.548; and intraoperative bleeding 394 ± 173.6 ml vs. 365.4 ± 168.5 ml, p = 0.550). However, estimated actual blood loss and postoperative bleeding differed between the groups (eABL 996.6 ± 348.3 ml vs. 858.5 ± 269.6 ml, p = 0.003; postoperative bleeding 601.8 ± 330.0 ml vs. 492.1 ± 277.1 ml, p = 0.016), and both increased in the combination group. No major bleeding was noted in the two groups. ConclusionPostoperative anticoagulant therapy does not have to be routinely used if mechanical prophylaxis is performed in patients without deep vein thrombosis before total hip arthroplasty.

Pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy.

Acute kidney injury (AKI) is a major comorbidity in hospitalised patients. Patients with severe AKI require continuous renal replacement therapy (CRRT) when they are haemodynamically unstable. CRRT is prescribed assuming it is delivered over 24 hours. However, it is interrupted when the extracorporeal circuits clot and the replacement is required. The interruption may impair the solute clearance as it causes under dosing of CRRT. To prevent the circuit clotting, anticoagulation drugs are frequently used. To assess the benefits and harms of pharmacological interventions for preventing clotting in the extracorporeal circuits during CRRT. We searched the Cochrane Kidney and Transplant Register of Studies up to 12 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We selected randomised controlled trials (RCTs or cluster RCTs) and quasi-RCTs of pharmacological interventions to prevent clotting of extracorporeal circuits during CRRT. Data were abstracted and assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) with 95% confidence intervals (CI). The primary review outcomes were major bleeding, successful prevention of clotting (no need of circuit change in the first 24 hours for any reason), and death. Evidence certainty was determined using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. A total of 34 completed studies (1960 participants) were included in this review. We identified seven ongoing studies which we plan to assess in a future update of this review. No included studies were free from risk of bias. We rated 30 studies for performance bias and detection bias as high risk of bias. We rated 18 studies for random sequence generation,ÃÂÃÂsix studies for the allocation concealment, three studies for performance bias, three studies for detection bias,ÃÂ nine studies for attrition bias,ÃÂ14 studies for selective reporting and nine studies for the other potential source of bias, as having low risk of bias. We identified eight studies (581 participants) that compared citrate with unfractionated heparin (UFH). Compared to UFH, citrate probably reduces major bleeding (RR 0.22, 95% CI 0.08 to 0.62; moderate certainty evidence) and probably increases successful prevention of clotting (RR 1.44, 95% CI 1.10 to 1.87; moderate certainty evidence). Citrate may have little or no effect on death at 28 days (RR 1.06, 95% CI 0.86 to 1.30, moderate certainty evidence). Citrate versus UFH may reduce the number of participants who drop out of treatment due to adverse events (RR 0.47, 95% CI 0.15 to 1.49; low certainty evidence). Compared to UFH, citrate may make little or no difference to the recovery of kidney function (RR 1.04, 95% CI 0.89 to 1.21; low certainty evidence). Compared to UFH, citrate may reduceÃÂthrombocytopenia (RR 0.39, 95% CI 0.14 to 1.03; low certainty evidence). It was uncertain whether citrate reduces a cost to health care services because of inadequate data. For low molecular weight heparin (LMWH) versus UFH, six studies (250 participants) were identified. Compared to LMWH, UFH may reduce major bleeding (0.58, 95% CI 0.13 to 2.58; low certainty evidence). It is uncertain whether UFH versus LMWH reduces death at 28 days or leads to successful prevention of clotting. Compared to LMWH, UFH may reduce the number of patient dropouts from adverse events (RR 0.29, 95% CI 0.02 to 3.53; low certainty evidence). It was uncertain whether UFH versus LMWH leads to the recovery of kidney function because no included studies reported this outcome. It was uncertain whether UFH versus LMWH leads to thrombocytopenia. It was uncertain whether UFH reduces a cost to health care services because of inadequate data. For the comparison of UFH to no anticoagulation, one study (10 participants) was identified. It is uncertain whether UFH compare to no anticoagulation leads to more major bleeding. It is uncertain whether UFH improves successful prevention of clotting in the first 24 hours, death at 28 days, the number of patient dropouts due to adverse events, recovery of kidney function, thrombocytopenia, or cost to health care services because no study reported these outcomes. For the comparison ofÃÂcitrate to no anticoagulation,ÃÂno completed study was identified. Currently,ÃÂavailable evidence does not support the overall superiority of any anticoagulant to another. Compared to UFH, citrate probably reduces major bleeding and prevents clotting and probably has little or no effect on death at 28 days. For other pharmacological anticoagulation methods, there is no available data showing overall superiority to citrate or no pharmacological anticoagulation. Further studies are needed to identify patient populations in which CRRT should commence with no pharmacological anticoagulation or with citrate.

Anticoagulation in COVID - 19: An Update.

The novel coronavirus disease, 2019 (COVID – 19) evolved as an unprecedented pandemic. The severe acute respiratory syndrome-corona virus-2 (SARS-CoV-2) infection has been associated with significantly deranged coagulation parameters and increased incidence of thrombotic events. Deranged coagulation parameters, such as D-dimers and fibrin degradation products, can indicate a poor prognosis, and their measurement will help stratify the patients according to the disease severity, need of intensive care unit admission, and prediction of the clinical course. Gaps in understanding the natural history of the disease cause difficulties in tailoring therapies and optimizing the management of patients. Lack of specific treatment further complicates this situation. While thrombotic events can cause significant morbidity and mortality in patients, a focused approach to the prevention and treatment of venous thromboembolism (VTE) can, to a great extent, decrease the disease burden caused by thrombotic diseases. Pharmacological prophylactic anticoagulants and mechanical therapies such as pneumatic compression devices can help prevent venous thromboembolism and other thrombotic events. Thrombotic events due to COVID-19, their prevention and management, are the focus of this paper, with the prospect of providing insights into this relatively unexplored area.

Venous Thromboembolism Prophylaxis in Adolescent Patients with Sickle Cell Disease: A Multicenter Cohort Study

Background: Evolving pediatric data, including case reports, case series, and combined adult and adolescent cohort studies, suggest an increased prevalence of venous thromboembolism (VTE) in children with Sickle Cell Disease (SCD) who undergo central venous catheter (CVC) placement (Ko RH and Thornburg C, Front Pediatr, 2017). Additionally, VTE has been shown to affect patients with SCD at a younger age compared to African-American controls (Stein PD, et al, Am J Med, 2006). Anecdotally, pediatric hematologists acknowledge the VTE risk in pediatric patients with SCD and have been using thromboprophylaxis in their patients despite the lack of standardized guidelines. The goal of this retrospective cohort study is to assess the utilization of pharmacologic and non-pharmacologic thromboprophylaxis in adolescent patients with SCD using a large pediatric database. Methods: The data source for this multicenter cohort study was the Pediatric Health Information Systems (PHIS), an administrative database that contains clinical and resource utilization data for inpatient, ambulatory surgery, emergency department, and observation unit patient encounters for 49 freestanding children's hospitals in the US. ICD-9-CM and ICD-10-CM codes were used to identify subjects, including SCD genotype (SS, SC and SB0 thal) and other comorbidities (acute chest syndrome, vaso-occlusive crisis, osteomyelitis, and bacteremia). We included subjects, aged 13-21 years, admitted to any PHIS hospital between 01/01/2010 - 12/31/2019. Subjects with a history of VTE were excluded. Supply billing codes were used to identify CVC placement and mechanical prophylaxis. Pharmaceutical billing codes were used to identify anticoagulant use. Results: 6,903 unique patients (3,147 male) met inclusion criteria with a median age of 17.2 years (13.0-21.9 years). These patients comprised a total of 33,298 admissions, with 2,434 (7.3%) admissions identified as receiving pharmacologic or mechanical prophylaxis (Table 1). 4.3% of the total admissions received mechanical prophylaxis and 3.3% received pharmacologic prophylaxis. Enoxaparin was the most commonly used anticoagulant, utilized in 91.3% of admissions in which pharmacologic anticoagulation was prescribed. The use of thromboprophylaxis was noted to increase over the study period, with significant increases observed in both pharmacologic and mechanical prophylaxis(p&amp;lt;.0001; Figure 1). The percentage of unique patients receiving thromboprophylaxis at each participating institution is shown in Figure 2. WConclusions: Use of both pharmacologic and mechanical thromboprophylaxis in hospitalized adolescent patients with SCD has increased in the last decade. However, there is variability amongst pediatric hospitals regarding the use and preferred method of thromboprophylaxis. Prospective cohort studies are needed to determine VTE risk factors in adolescents and children with SCD and the efficacy of prophylaxis regimens. These studies will help guide the development of VTE prophylaxis regimens. Disclosures Davila: ATHN: Other: Grant Funding; Spire Learning: Speakers Bureau. O'Brien:Bristol Myers Squibb: Consultancy, Membership on an entity's Board of Directors or advisory committees. OffLabel Disclosure: The use of Direct Oral Anticoagulants and Enoxaparin in children