Strategies For Management Of Bleeding Research Articles

Strategies for the Effective Management of Bleeding in Trauma Patients: A Narrative Review

Strategies for the Effective Management of Bleeding in Trauma Patients: A Narrative Review

MANAGEMENT OF BLEEDING AFTER ENDOSCOPIC BILIARY SPHINCTEROTOMY IN PATIENTS WITH OR WITHOUT COAGULOPATHY DEFECTS

Background: Post Endoscopic sphincterotomy (ES) bleeding is a common complication, and it can be challenging to manage post ES bleeding through a side-viewing endoscope. Objective: To establish a well-accepted clinical strategy for management of bleeding after endoscopic biliary sphincterotomy in patients with or without coagulopathy defects. Patients and Methods: This prospective interventional selective study was carried out on 100 consecutive patients with jaundice at General Surgery Department, Al- Azhar University Hospitals (Cairo) Egypt. All patients underwent ERCP during the period between January 2016 and August 2019. Patients were divided into 2 equal groups according to presence or absence of coagulopathy: Group A without coagulopathy defect, and group B with coagulopathy defect. Results: Among 100 patients with endoscopic retrograde cholangiopancreatography (ERCP), post ES bleeding was recorded in 33 patients. Only 1 of 33 was among group A which represented 3% of bleeding cases, and 1% of the total. The cause was vigorous sphincterotomy. Of 33 patients, 32 were among group B, and represented 97% of bleeding cases, and 32% of total cases in our study. The arrangement of the use of different hemostatic measures in our study was based on accessibility of the facilities and also severity of bleeding. In mild cases, bleeding stopped simply with balloon tamponade. If not, adrenaline spray was used. Endoclip was used for difficult and recurrent cases. Delayed bleeding occurred (1±7 days -mean, 2.5 days) following the procedures. Among the 9 patients with delayed bleeding, 7 patients were managed by endoscopic intervention. The other 2 patients managed conservatively by drugs and intravenous fluids with. No patient required angiography or surgery for delayed bleeding. Conclusion: Patients must be carefully assessed and prepared pre procedure. Centers must be equipped with all hemostatic measures and facilities. Endoscopists must be well trained and qualified. Bleeding was controlled in all patients easily without morality.

MANAGEMENT OF BLEEDING AFTER ENDOSCOPIC BILIARY SPHINCTEROTOMY IN PATIENTS WITH OR WITHOUT COAGULOPATHY DEFECTS

Background: Post Endoscopic sphincterotomy (ES) bleeding is a common complication, and it can be challenging to manage post ES bleeding through a side-viewing endoscope. Objective: To establish a well-accepted clinical strategy for management of bleeding after endoscopic biliary sphincterotomy in patients with or without coagulopathy defects. Patients and Methods: This prospective interventional selective study was carried out on 100 consecutive patients with jaundice at General Surgery Department, Al- Azhar University Hospitals (Cairo) Egypt. All patients underwent ERCP during the period between January 2016 and August 2019. Patients were divided into 2 equal groups according to presence or absence of coagulopathy: Group A without coagulopathy defect, and group B with coagulopathy defect. Results: Among 100 patients with endoscopic retrograde cholangiopancreatography (ERCP), post ES bleeding was recorded in 33 patients. Only 1 of 33 was among group A which represented 3% of bleeding cases, and 1% of the total. The cause was vigorous sphincterotomy. Of 33 patients, 32 were among group B, and represented 97% of bleeding cases, and 32% of total cases in our study. The arrangement of the use of different hemostatic measures in our study was based on accessibility of the facilities and also severity of bleeding. In mild cases, bleeding stopped simply with balloon tamponade. If not, adrenaline spray was used. Endoclip was used for difficult and recurrent cases. Delayed bleeding occurred (1±7 days -mean, 2.5 days) following the procedures. Among the 9 patients with delayed bleeding, 7 patients were managed by endoscopic intervention. The other 2 patients managed conservatively by drugs and intravenous fluids with. No patient required angiography or surgery for delayed bleeding. Conclusion: Patients must be carefully assessed and prepared pre procedure. Centers must be equipped with all hemostatic measures and facilities. Endoscopists must be well trained and qualified. Bleeding was controlled in all patients easily without morality.

Viscoelastic testing in pediatric patients.

A tailored transfusion algorithm based on viscoelastic testing in the perioperative period or in trauma patients is recommended by guidelines for bleeding management. Bleeding management strategies in neonates and children are mostly extrapolated from the adult experience, as published evidence in the youngest age group is scarce. This manuscript is intended to give a structured overview of what has been published on the use of viscoelastic testing to guide bleeding management in neonates and children. Several devices that use either the traditional viscoelastic method or resonance viscoelastography technology are on the market. Reference ranges for children have been evaluated in only some of them. As most of the hemostasis maturation processes can be observed during the first year of life, adult reference ranges for viscoelastic testing could be applied over the age of 1 year. The majority of the published trials in children are based on retrospective analyses describing the correlation between viscoelastic testing and standard laboratory testing or focusing on the prediction of bleeding. Clinically more relevant studies in pediatric patients undergoing cardiac surgery have demonstrated that the implementation of a transfusion algorithm based on viscoelastic testing has significantly reduced transfusion requirements and that this approach has enabled a rapid detection of coagulation disorders in the presence of excessive bleeding. Although further studies are urgently needed, experts have reviewed the use of a transfusion algorithm based on viscoelastic testing in children as a feasible approach, as it has been shown to improve bleeding management and rationalize blood product transfusion.

Managing Nonoperable Intracranial Bleeding Associated With Apixaban: A Series of 2 Cases

Objective: To report 2 cases of nonoperable intracranial bleeding associated with apixaban managed by 3-factor prothrombin complex concentrate (PCC3). Case Summaries: Case 1 presented with a 1.3-cm left parieto-occipital hemorrhage and a thin subdural hematoma (SDH) on the left tentorium of the brain about 6 hours after his last dose of apixaban. Case 2 presented with a 4-mm left parafalcine SDH with time of most recent apixaban dose unknown. The patients received 24.9 to 25.5 U/kg of PCC3 with none to 1 U fresh frozen plasma (FFP) and demonstrated minimal or no progression in lesions measured by repeat computed tomography (CT) after treatment. One patient was discharged to a skilled nursing facility after 8 days; the other patient was discharged to home after 18 days. Discussion: Apixaban has no specific antidote. Current bleeding management strategies are based on expert opinion. The risks and benefits for differing strategies are unclear, and little clinical experience for managing apixaban-associated intracranial bleeding has been reported to date. These cases describe the clinical use of PCC3 to manage parieto-occipital and subdural hemorrhage associated with apixaban in events not requiring surgical intervention. Conclusion: In these 2 cases, 25 U/kg PCC3, with none to one unit FFP, ceased apixaban-associated intracranial bleeding without apparent thrombogenic complications.

Abstract TP280: AF and Urgent Bleeding Management Strategies: Effect of Online CME

Introduction: Although anticoagulant therapy with non-vitamin K antagonist oral anticoagulants (NOACs) has demonstrated safety in multiple clinical trials in the setting of stroke prevention in atrial fibrillation (SPAF), a small percentage of patients experience urgent bleeding, which may require advanced bleeding management strategies, including NOAC reversal. Hypothesis: A video-based online continuing medical education (CME) activity can improve the knowledge and competence of cardiologists regarding strategies for managing anticoagulant-related urgent bleeding events Methods: An online CME activity was developed as a 25-minute roundtable discussion with 4 leading experts. The activity included a transcript of the discussion and a downloadable slide deck to highlight and reinforce key data. The effects of education were assessed using a linked pre-assessment/post-assessment study design. For all questions combined, the McNemar’s chi-square test was used to assess differences from pre- to post-assessment. P values are shown as a measure of significance; P values <.05 are statistically significant. Cramer’s V was used to calculate the effect size (>30=large effect size, 0.16-0.30=medium effect size, <0.16=small effect size) Results: For cardiologists who participated in the CME activity, comparison of individually linked pre-assessment question responses to the respective post-assessment question responses demonstrates statistically significant improvements (N = 187; P =0.002). A total of 33% of cardiologists answered all 4 pre-assessment questions correctly with 48% answering all post-assessment questions correctly. Significant mprovements were demonstrated: 1) A 23% relative improvement in the knowledge of the mechanism of action for idarucizumab (70% pre-assessment vs 86% post-assessment; P<0.001; V=0.194); 2) A 22% relative improvement in the knowledge of the specificity of andexanet alfa (69% vs 84%; P<0.05; V=0.176). Conclusion: The statistically significant improvements observed in this online CME roundtable discussion demonstrate the benefits of educating the appropriate target audience base with aptly designed educational activities.

Hemostasis and Thrombosis in Major Liver Resection

The liver plays an important role in the balance between hemostasis and thrombosis. Hepatic resection, particularly when performed in the presence of underlying parenchymal liver disease, can cause perturbation of this balance. This review summarizes the changes that occur in normal hemostasis and thrombosis before, during, and after nontransplant hepatic resection and, wherever possible, provides strategies for the perioperative management of bleeding and thrombosis.

Issues with new oral anticoagulants-monitoring and management of bleeding

The new oral anticoagulant agents are now available through the PBS for the prevention of thromboembolic complications of atrial fibrillation and the treatment and prevention of venous thrombosis. While more convenient to use than traditional vitamin K antagonists, concerns were initially raised regarding the safety of these agents in a ‘real-life’ setting, particularly given the lack of availability of a validated reversal strategy. Available post-marketing surveillance data to date has been reassuring. This talk will detail current data regarding the ability to assess the anticoagulant effect of the direct thrombin and direct factor Xa inhibitors with both conventional and specific assays. Current recommended strategies for management of bleeding in patients on new oral anticoagulants will be discussed, including the potential clinical implication of the lack of a validated reversal agent. Future specific reversal strategies will also be covered.

A Brief Review of 50 Years of Perioperative Thrombosis and Hemostasis Management

Perioperative thrombosis and hemostasis management has changed dramatically over the past 50 years. From two anticoagulants and one anti-aggregant, the number of currently available drugs has recently increased several-fold, leaving clinicians with the problem of choosing the optimal agent. Individualized preoperative assessment of bleeding risk based on bleeding history and testing limited to high-risk patients is an emerging concept. Based on the identification of risk factors for venous thromboembolism (VTE), pharmacologic and non-pharmacologic strategies for perioperative VTE prophylaxis have had a major impact on patient outcome. For patients undergoing surgery who are treated with anticoagulants and anti-aggregants, "bridging" strategies have been proposed. Bleeding management strategies have shifted focus from replacing lost blood volume to new approaches aimed at preventing blood loss, reducing the potential complications of blood loss, and preventing the transfusion of blood products. For some areas of perioperative thrombosis and hemostasis management, randomized controlled trial (RCT) data are emerging, but the database remains insufficient to date. Clearly, more RCTs need to be published for perioperative thrombosis and hemostasis management to become an evidence-based approach.

Emergency Management of Bleeding Associated With Old and New Oral Anticoagulants

As major prescribers of oral anticoagulants, cardiologists must be familiar with strategies to manage bleeding, the principal complication associated with all anticoagulants, and to reverse anticoagulant effects in acute-care settings. The purpose of this manuscript is to review currently available information regarding dabigatran and rivaroxaban, the 2 novel oral anticoagulants approved to date in the United States. Further, we suggest reasonable interventions for the clinician faced with a patient who suffers a major bleeding event while receiving one of these agents. Data sources were peer-reviewed publications, US Food and Drug Administration documents in the public domain, and approved US prescribing information for dabigatran (Pradaxa) and rivaroxaban (Xarelto). Strategies for management of bleeding and reversal of anticoagulant effects from warfarin include vitamin K, fresh frozen plasma, and prothrombin complex concentrates. For rivaroxaban and dabigatran, appropriate therapies include support and observation, which are likely to be effective for the majority of patients because of the short half-lives of these agents. In severe life-threatening hemorrhage, clotting-factor substitutes may be appropriate in certain situations. Validated protocols specific to each agent remain to be developed.

Management of dental patients taking common hemostasis-altering medications

Millions of patients worldwide are taking medications that alter hemostasis and decrease the risk for thromboembolic events. This systematic review is intended to provide recommendations regarding optimal management of such patients undergoing invasive dental procedures. The primary focus of this report is on warfarin therapy, although issues related to heparin and aspirin are briefly discussed because of the frequency with which they are encountered in dental practice. The review of literature and development of recommendations was based on the Reference Manual for Management Recommendations for the World Workshop in Oral Medicine IV (WWOM IV). A total of 64 publications were identified for initial review. From these publications, the following types of articles were critically analyzed using WWOM standard forms: randomized controlled trials (RCT), non-RCT studies that assess effects of interventions, and studies that assess modifiable risk factors. Development of recommendations was based on the findings of these reviews as well as expert opinion. The following evidence-based recommendations were developed: (1) For patients within the therapeutic range of International Normalized Ratio (INR) below or equal to 3.5, warfarin therapy need not be modified or discontinued for simple dental extractions. Nevertheless, the clinician's judgment, experience, training, and accessibility to appropriate bleeding management strategies are all important components in any treatment decision. Patients with INR greater than 3.5 should be referred to their physician for consideration for possible dose adjustment for significantly invasive procedures. (2) A 2-day regimen of postoperative 4.8% tranexamic acid mouthwash is beneficial after oral surgical procedures in patients on warfarin. (3) It is not necessary to interrupt low-dose aspirin therapy (100 mg/day or less) for simple dental extractions. For most patients undergoing simple single dental extractions, the morbidity of potential thromboembolic events if anticoagulant therapy is discontinued clearly outweighs the risk of prolonged bleeding if anticoagulant therapy is continued.

Hemorrhaging associated with endosseous implant placement in the anterior mandible: a review of the literature.

The placement of endosseous dental implants is largely considered a safe surgical procedure. However, upper airway obstruction secondary to severe bleeding in the floor of the mouth has been occasionally reported as a rare but potentially fatal complication of implant surgery. This review presents critical hemorrhagic episodes, related to dental implantation in the anterior segments of the mandible, published to date. Massive internal bleeding in the highly vascularized region of the floor of the mouth is the result of an arterial trauma induced by instrumentation, usually through a perforation of the lingual cortical plate. Depending on the clinical situation, hemorrhage may commence immediately or with some delay after the vascular insult. The progressively expanding lingual, sublingual, submandibular, and submental hematomas have the tendency of displacing the tongue and floor of the mouth to obstruct the airway. Because the course of airway deterioration to complete occlusion may be rapid, ensuring a patent airway is of highest priority. Even though upper airway obstruction is potentially life-threatening, a secure airway was successfully established in all patients without fatal consequences. In most cases, resolution of hemorrhage required a surgical intervention for ligation of the bleeding vessels and hematoma evacuation. To reduce the probability of such a grave complication, preventive and precautionary measures to be taken before, during, and after implant placement in the anterior mandible are presented. Issues related to the level of surgical experience, fine regional arterial anatomy, radiographic and clinical evaluation of the osseous morphology, angulation and length of implants, and timing of hemorrhage onset are discussed. In addition, airway and bleeding management strategies are provided.