Use Of Antifibrinolytics Research Articles

Vasospasm management: a meta-synthesis of current modalities used by different medical societies

Background: Cerebral vasospasm is a life-threatening complication of an aneurysmal subarachnoid hemorrhage (aSAH), with approximately 6 to 10 cases per 100,000 patients yearly. Despite the publication of numerous guidelines from various medical societies, there is a lack of standardized consensus on what the optimal management strategies for this severe complication truly are. This meta-synthesis aims to synthesize these endorsed recommendations to ultimately identify standardized care guidelines and improve patient outcomes after aSAH. Methods: A comprehensive database search of existing guidelines published by major medical societies in the past 10 years was performed. Results: The analysis included 28 relevant documents from 7 major medical societies. Key findings included: 1) Unanimous endorsement for oral nimodipine administration for 21 days post-aSAH. 2) Varying recommendations for alternative calcium channel blockers and hemodynamic management methods. 3) Targeted hypermagnesemia and routine statin therapy were not universally recommended due to insufficient evidence. 4) Use of antifibrinolytics was considered on a case-by-case basis. 5) Endovascular interventions were recommended for refractory cases, specifically. Conclusion: This meta-synthesis reveals consistencies and divergences in vasospasm management recommendations across medical societies, highlighting the need for more robust clinical trials, regular guideline updates, and increased medical society collaboration. Keywords: Vasospasm, cerebral vasospasm, aSAH, management, guidelines, meta-synthesis

205: Use of Antifibrinolytics in pediatric patients on ECMO

205: Use of Antifibrinolytics in pediatric patients on ECMO

Anti-fibrinolytics for mucosal bleeding in adults with life-limiting illnesses: a systematic review

IntroductionPatients with life-limiting illnesses are at increased risk of mucosal bleeding. Usual management includes anticipatory planning and sedation, alongside anti-fibrinolytics, despite a lack of evidence for their use. Anti-fibrinolytic agents...

The use of fibrinolysis inhibitors in cardiac surgery with cardiopulmonary bypass (literature review)

In cardiac surgery with cardiopulmonary bypass (CPB) is a common complication. The incidence of this complication in cardiac surgery patients is estimated at about 10%. For this reason, the introduction of a patient blood management (PBM) in cardiac surgery is extremely relevant. Antifibrinolytic therapy is a key pharmacological tool of a multimodal PBM in cardiac surgery with CPB. The use of antifibrinolytics (tranexamic acid (TXA) and epsilon aminocaproic acid (EACA)) is standard practice in complex cardiac surgery with CPB. However, there is currently ongoing discussion regarding the search for the optimal dose of EACA and TXA to achieve an effective concentration in blood plasma in order to inhibit fibrinolysis with the minimization of adverse events. The use of aprotinin has a number of potential advantages, but its use in routine clinical practice is significantly limited. This review presents modern approaches to antifibrinolytic therapy, examines the mechanisms of action of the main drugs, highlights the side effects associated with the use of antifibrinolytic agents.

Antifibrinolytic and Adjunct Hemostatic Agents: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference.

To derive systematic-review informed, modified Delphi consensus regarding antifibrinolytic and adjunct hemostatic agents in neonates and children supported with extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE consensus conference. A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. Use of antifibrinolytics (epsilon-aminocaproic acid [EACA] or tranexamic acid), recombinant factor VII activated (rFVIIa), or topical hemostatic agents (THAs). Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Eleven references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. One weak recommendation and three consensus statements are presented. Evidence supporting recommendations for administration of antifibrinolytics (EACA or tranexamic acid), rFVIIa, and THAs were sparse and inconclusive. Much work remains to determine effective and safe usage strategies.

Emergent Management of Spontaneous Subarachnoid Hemorrhage.

Spontaneous subarachnoid hemorrhage (SAH) carries high morbidity and mortality rates, and the emergent management of this disease can make a large impact on patient outcome. The purpose of this article is to provide a pragmatic overview of the emergent management of SAH. Recent trials have influenced practice around the use of antifibrinolytics, the timing of aneurysm securement, the recognition of cerebral edema and focus on avoiding a lower limit of perfusion, and the detection and prevention of delayed cerebral ischemia. Much of the acute management of SAH can be protocolized, as demonstrated by two updated guidelines published by the American Heart Association/American Stroke Association and the Neurocritical Care Society in 2023. However, the gaps in evidence lead to clinical equipoise in some aspects of critical care management. In acute management, there is an urgency to differentiate the etiology of SAH and take key emergent actions including blood pressure management and coagulopathy reversal. The critical care management of SAH is similar to that of other acute brain injuries, with the addition of detecting and treating delayed cerebral ischemia. Strategies for the detection and treatment of delayed cerebral ischemia are limited by disordered consciousness and may be augmented by monitoring and imaging technology.

Surgical Procedures and Hemostatic Outcome in Patients with Hemophilia Receiving Concizumab Prophylaxis during the Phase 3 explorer7 and explorer8 Trials

Introduction Concizumab is an anti-tissue factor pathway inhibitor monoclonal antibody that has been developed for once-daily subcutaneous prophylactic treatment for hemophilia of all subtypes. The phase 3 explorer7 (NCT04083781) and explorer8 trials (NCT04082429) investigated the efficacy and safety of concizumab prophylaxis in patients with hemophilia A or B with (HAwI/HBwI, explorer7) or without (HA/HB, explorer8) inhibitors. Aim To provide an overview of any surgical procedures at the 56-week cut-off performed on patients who received concizumab prophylaxis in the explorer7 and explorer8 trials. Methods Patients in both explorer7 and explorer8 trials were exposed to no prophylaxis (arm 1) or concizumab prophylaxis (arms 2-4) based on their treatment regimen before the trial. After the main part of the trial, all patients (arms 1-4) could continue in the extension part of the trial receiving concizumab for up to 136 weeks. Informed consent/ethics committee approvals were obtained as appropriate. Minor surgical procedures (defined as any invasive operative procedure where only the skin, mucous membranes or superficial connective tissue is manipulated) were permitted during the explorer7 and explorer8 trials, and management of minor surgeries was at the investigator's discretion. Planned major surgery was not permitted, and for any cases of acute major surgery, a concizumab pause was recommended. Data regarding both minor and major surgeries undertaken in patients were collected at the 56-week cut-off of the trials. Local/topical use of anti-fibrinolytics was permitted during surgical procedures in both trials (single systemic doses allowed following benefit-risk evaluation) and patients undergoing minor surgical procedures continued to receive concizumab prophylaxis during the perioperative period (with no change to the dosage they received). Results During both trials, a total of 278 patients received concizumab prophylaxis. Of these, 30 patients underwent a minor surgical procedure, including 6 (20.0%) adolescents (aged 12-17 years) and 24 (80.0%) adults (aged 18-64 years). Nine patients who underwent a minor procedure had HA (30.0%), 10 had HB (33.3%), 7 had HAwI (23.3%) and 4 had HBwI (13.3%). Four patients underwent both major and minor surgeries and 2 patients underwent major surgeries only. In total, 44 surgical procedures were undergone in 32 patients. The surgical procedures that were performed in patients who received concizumab included a range of minor surgeries in both trials (including tooth extractions and other dental procedures, port removal, colonoscopy, arthrodesis and urethral augmentation). Overall, 6 cases of major surgery were reported during the explorer7 and explorer8 trials (left hip arthropathy, hematoma drainage, right femoral neck fracture, total knee arthroplasty, right ankle arthropathy and diagnostic laparoscopy with removal of blood from the abdominal cavity) in 1 patient with HA, 2 patients with HB, 1 patient with HAwI and 2 patients with HBwI respectively. Bleeding episodes related to minor and major surgical procedures (n=30) were reported in 24 patients and in 15 of these a total of 17 bleeding episodes were treated. The majority of patients (n=12) who reported a treated surgical-related bleeding episode had undergone a dental surgical procedure. Other minor surgical procedures with associated bleeding episodes included port removal, and venesection. The number and type of minor surgical procedures are further described in Table 1. Conclusion Minor surgical procedures were conducted in approximately 11% of patients who received treatment with concizumab during the phase 3 explorer7 and explorer8 trials. Most minor surgeries that took place were dental procedures and the majority of surgical-related bleeding episodes were mild or moderate. Overall, minor surgeries could be performed on patients with hemophilia under concizumab prophylaxis.

Successful Management of Intracranial Hemorrhage with Emicizumab in a Newborn with Severe Hemophilia a: A Case Report

Introduction Intracranial hemorrhage (ICH) is the second most common first hemorrhage in neonates with congenital Hemophilia, with an incidence of 3.4-4.0%. Nearly half (41%) of ICHs occur within the first week of life. ICH is the most feared complication of hemophilia with a high rate of morbidity and up to 20% of mortality. Timely diagnosis and prompt treatment are critical, even though the clinical signs of ICH in neonates are difficult to assess. Most studies recommend infusion of Factor VIII (FVIII) rising its plasma level to 100% as soon as possible. Unfortunately, approximately 25% to 40% of neonates develop inhibitors against FVIII after substitutive treatment; the percentage may be even higher in neonates with ICH requiring prolonged continuous treatment over days to weeks. We report a case of ICH in a newborn with severe haemophilia A (HA) treated with an initial-single dose of FVIII concentrate and then only with emicizumab. Case report A male neonate, born at 38+4 weeks of gestation by cesarean delivery, presented abnormal bleeding on his third day of life after heel blood sampling. Activated Partial Thromboplastin test resulted 147 seconds and FVIII was less then 1%. Family history for bleeding disorders was negative. A cerebral ultrasound scan documented a brain area suspicious for intracranial hemorrhage. Before transferring the neonate to the neonatal intensive care unit (NICU), he received an additional intravenous dose of vitamin K and 10 ml/kg fresh frozen plasma. On admission in NICU, the neonate presented alert and responsive with stable hemodynamics and vital signs. A second brain ultrasound and head MRI confirmed an intracerebral hemorrhage in the left parieto-occipital area near the splenium of the corpus callosum associated with subdural hematoma in the left temporo-occipital, occipito-mesial area, in falx cerebri and left tentorium cerebelli. Neonate received tranexamic acid infusions 40 mg/kg die and 50 IU/Kg of intravenous recombinant factor VIII concentrate (octocog alfa). Then, it was decided to start treatment with Emicizumab, a bispecific antibody mimicking FVIII, at a dose of 3 mg/kg subcutaneously once a week for 4 weeks, continuing prophylaxis at 1.5 mg/kg once a week.Serial brain ultrasound revealed progressive reduction of the ICH extension over the following weeks; one month later, brain MRI confirmed the improvement. The neonate's clinical condition remained always stable; he never showed seizures or neurological signs of impaired consciousness and his neurodevelopment is appropriate for age. MRI performed at three months of age documented complete resolution of the cerebral hemorrhage. Discussion Intensive FVIII replacement therapy for ICH in pups is associated with a high risk of inhibitor formation.Emicizumab, a humanised bispecific monoclonal antibody, is indicated for routine prophilaxis in patients with severe HA with and without antibodies to FVIII. Emicizumab is attractive due to its weekly or even longer dosing intervals and subcutaneous route of administration but, despite the baseline hemostasis achieved with emicizumab, acute bleeding events may still require aggressive therapy. Theoretically, it needs few days to be hemostatically effective but its in vitro coagulant potential in neonate is heterogeneous, thus we can not completely explain the therapeutic success with only one dose of FVIII. Conclusions The combined use of emicizumab and antifibrinolytics was successful in treating acute intracranial hemorrhage. To the best of our knowledge, this is the first pediatric case of successful management of intracranial hemorrhage with emicizumab in a newborn with severe HA.

Fifteen Years of Spinal Fusion Outcomes in Children With Cerebral Palsy: Are We Getting Better?

Retrospective multicenter study. We reviewed 15-year trends in operative factors, radiographic and quality of life outcomes, and complication rates in children with cerebral palsy (CP)-related scoliosis who underwent spinal fusion. Over the past two decades, significant efforts have been made to decrease complications and improve outcomes of this population. We retrospectively reviewed a multicenter registry of pediatric CP patients who underwent spinal fusion from 2008 to 2020. We evaluated baseline and operative, hospitalization, and complication data as well as radiographic and quality of life outcomes at a minimum 2-year follow-up. Mean estimated blood loss and transfusion volume declined from 2.7±2.0L in 2008 to 0.71±0.34L in 2020 and 1.0±0.5L in 2008 to 0.5±0.2L in 2020, respectively, with a concomitant increase in antifibrinolytic use from 58% to 97% (all, P <0.01). Unit rod and pelvic fusion use declined from 33% in 2008 to 0% in 2020 and 96% in 2008 to 79% in 2020, respectively (both, P <0.05). Mean postoperative intubation time declined from 2.5±2.6 to 0.42±0.63 days ( P< 0.01). No changes were observed in preoperative and postoperative coronal angle and pelvic obliquity, operative time, frequency of anterior/anterior-posterior approach, and durations of hospital and intensive care unit stays. Improvements in the Caregiver Priorities and Child Health Index of Life with Disabilities postoperatively did not change significantly over the study period. Complication rates, including reoperation, superficial and deep surgical site infection, and gastrointestinal and medical complications remained stable over the study period. Over the past 15 years of CP scoliosis surgery, surgical blood loss, transfusion volumes, duration of postoperative intubation, and pelvic fusion rates have decreased. However, the degree of radiographic correction, the rates of surgical and medical complications (including infection), and health-related quality of life measures have broadly remained constant.

A survey evaluating practice pattern in management of obstetric hemorrhage.

Hemorrhage anticipation and management has shifted significantly over the past decade due to evolution of data surrounding management of obstetric hemorrhage. Limited data exists which describe the practical use and clinical application of hemorrhage management. Our goal was to identify obstetric hemorrhage management patterns in a cohort of practicing Maternal Fetal Medicine physicians. We administered a survey to Maternal Fetal Medicine (MFM) fellows and faculty that addressed the management of hemorrhage including risk assessment, uterotonic use, antifibrinolytic use, cell saver use, and abnormal placentation management. An email was sent out regarding the survey to a listserv of all Maternal Fetal Medicine fellow program coordinators to disseminate to their faculty and fellows. Eighty responses were obtained. A total of 78 surveys were analyzed. Participants preferred methylergonovine as a first line agent (n = 57; 73%, n = 62; 80%). Most participants would consider using cell salvage when also activating MTP (28, 48%) or during scheduled deliveries who are high risk of hemorrhage (40, 69%). Approximately a third of providers would use TXA (tranexamic acid) prophylactically (n = 21; 28%). Only 26% of MFM fellows felt comfortable performing cesarean hysterectomy without Gynecologic Oncology. In comparison to prior reports, TXA use has increased substantially. Further, when looking at the management of abnormal placentation, the use of magnetic resonance imaging and embolization have both increased. Possibly due to the rise in centers of excellence for treatment of accreta spectrum disorders, Maternal Fetal Medicine fellows still feel largely unprepared to perform a cesarean hysterectomy without Gynecologic Oncology.

Evaluation of Therapeutic Use of Antifibrinolytics in Cats

ABSTRACT Limited data are available regarding the use of the antifibrinolytic drugs tranexamic acid (TXA) and epsilon aminocaproic acid (EACA) in cats. This study aimed to evaluate the indications for the use of TXA and EACA in cats and to describe dosing regimens used, occurrence of adverse events, and patient outcomes. This was a retrospective multicenter study. Medical databases were searched for feline patients billed for TXA or EACA between 2015 and 2021. Thirty-five cats met the inclusion criteria; 86% received TXA and 14% received EACA. The most common indication was nontraumatic hemorrhage (54%), followed by traumatic hemorrhage (17%) and elective surgery (11%). The median dose was 10 mg/kg for TXA and 50 mg/kg for EACA. Overall, 52% of cats survived to discharge. Potential adverse events were noted in 7/35 (20%) patients. Of these, 29% survived to discharge. No standardized dosing regimen was identified; rather, dose, dosing interval, and duration of administration varied markedly between patients. Administration was potentially associated with severe adverse events, although the retrospective design makes it difficult to establish a causal association with antifibrinolytic use. This study provides a base for future prospective studies by giving an insight into the use of antifibrinolytic drugs in cats.

Rapid resolution of hyperfibrinolysis in dogs with spontaneous hemoperitoneum following surgical control of hemorrhage

To estimate the point prevalence and duration of hyperfibrinolysis (HF) in dogs undergoing surgical control of spontaneous hemoperitoneum (SHP). Prospective observational study. Single veterinary teaching hospital. Forty-five client-owned dogs with SHP were screened for HF. Eighteen HF dogs treated surgically were studied. None. Dogs with SHP and evidence of shock admitted for surgical control of hemorrhage were screened for HF. Blood samples were collected for PCV, total plasma protein, platelet count, and thromboelastography with 50U/mL of tissue plasminogen activator at presentation and every 8hours postoperatively until 72hours, discharge, or death. HF was defined as a tissue plasminogen activator-activated thromboelastography lysis percentage measured 30minutes after maximum amplitude (LY30) of ≥20%. LY30 values were compared to a cohort of samples obtained from healthy dogs (n=22). The point prevalence of HF in all dogs screened was 40% (18/45 dogs), and the mean LY30 at baseline for HF dogs was 48.9% (±24.2%), which was significantly higher than that of control dogs (4.8%±7.1%, P<0.001) and non-HF dogs (1.9%±5.7%, P<0.001). In HF dogs, there was a significant decrease in LY30 between baseline and 8hours (P<0.0001) and between 8 and 16hours (P=0.035) but no significant change thereafter. LY30 at 8hours (4%, range: 0%-23.4%) was not statistically different from control dogs (6.5%, range: 1.2%-32.8%, P=0.664) suggesting early resolution of HF in this population. Only 2 of 18 dogs were persistently hyperfibrinolytic at 24hours. Malignancy was diagnosed in 12 of 18 dogs (66.6%), while a benign etiology occurred in 6 of 18 dogs (33.3%). All HF dogs survived to discharge. HF occurs in some dogs with hypovolemic shock due to hemoperitoneum but resolves rapidly following surgical control of bleeding without antifibrinolytic medications. Routine postoperative use of antifibrinolytics in dogs with hemoperitoneum in dogs undergoing surgical control of bleeding may not be warranted.

Rare case of coagulative necrosis of uterine leiomyoma: Case report

Coagulative tumor necrosis or tumor cell necrosis is a very rare type of fibroid degeneration, commonly occurs in 80% of leiomyosarcomas, but it is rare in benign uterine leiomyomas. Women with menorrhagia have increased levels of plasminogen activators in endometrium and use of anti-fibrinolytics can enhance the formation of thrombus in leiomyoma. Degeneration like red and hyaline in uterine leiomyomas may be associated with pregnancy and use of progestogen or OCP’s but degeneration associated with use of anti-fibrinolytics can occur in any part of reproductive life. Materials and Methods: We present the case of 28yr lady with heavy menstrual bleeding and severe dysmenorrhea since 2 years, diagnosed with fibroid uterus and was on anti-fibrinolytics (Tranexamic acid) on and off for 2years. Finally underwent a myomectomy, wherein we found a cheesy degenerative material with final histopathology report revealing as coagulative tumor necrosis without any atypical cells. Conclusion: Coagulative necrosis is usually seen in malignant condition. Infarct type necrosis and thrombus was observed in benign leiomyoma, possibly secondary to prolonged, repetitive use of Tranexamic acid.

Thrombosis in hereditary hemorrhagic telangiectasia

Thrombosis in hereditary hemorrhagic telangiectasia

Safety and Efficacy of Tranexamic Acid in Hip Hemiarthroplasty for Fracture Neck Femur: a Systematic Review and Meta-analysis.

Although numerous systematic reviews and meta-analyses have established the efficacy of tranexamic acid (TXA) in hip fracture surgeries, the included studies in those reviews have included all types of surgical interventions ranging from fixation to arthroplasty. Hip hemiarthroplasty is usually indicated in the elderly patients with femoral neck fracture and these patients have associated severe comorbidities and cognitive impairment. These subsets of patients with femoral neck fracture needs appropriate perioperative care and judicious use of antifibrinolytics. There is no meta-analysis evaluating the safety and efficacy of intravenous TXA in these patients. Searches of PubMed, Embase and Cochrane Central Register of Controlled Trials databases revealed 102 studies on TXA in hip fracture surgeries. After screening, eight studies were found to be suitable for review. The primary objective of this meta-analysis was to compare blood transfusion rate between TXA vs. control in hip hemiarthroplasty. The secondary objectives were total blood loss, postoperative haemoglobin, surgical duration, length of hospital stay and side effects (VTE, readmission and 30 days mortality). There were one RCT, one prospective cohort study and six retrospective studies. All studies recruited the elderly patients. Intravenous (IV) TXA administration resulted in significant reduction in requirement of blood transfusion (12.7% vs. 31.9%; OR 0.28; 95% CI 0.17-0.46; p < 00,001; I 2 = 73%). The TXA group had significantly decreased total blood loss (MD -100.31; 95% CI -153.79, -46.83; p < 0.0002). The postoperative Hb in the TXA group was significantly higher than the control group (MD 0.53; 95% CI 0.35, 0.71; p < 0.00001). There was no significant difference in the incidences of VTE (0.97% vs. 0.73%, OR 1.27; p = 0.81; I 2 = 64%) and readmission rate (9.2% vs. 9.64%; OR 0.79; p = 0.54), but 30-d mortality rate was significantly lower in the TXA group (3.41% vs. 6.04%; OR 0.66; p = 0.03). Intravenous TXA is efficacious in the reduction of blood loss and transfusion need in hip hemiarthroplasty surgery for hip fracture, without increased risk of VTE. The blood conservation protocol led to decreased 30 days mortality in these fragile elderly patients. III.

Factors affecting need for blood transfusion in paediatric patients undergoing open surgery for hip dysplasia.

The management of intraoperative blood loss in the surgical treatment of paediatric hip dysplasia is resource intensive. There are numerous clinical factors that impact the need for intraoperative transfusion. Identification of patient and surgical factors associated with increased blood loss may reduce the unnecessary use of resources. This study aimed to identify factors predictive of intraoperative transfusion in children undergoing hip dysplasia surgery. This is a single-centre retrospective review of patients undergoing surgery for hip dysplasia from 1 January 2012 to 15 April 2021. Patient demographic factors, anaesthetic, surgical and transfusion histories were reviewed. Multivariable logistic regression analysis was performed to identify factors predictive of allogeneic red blood cell transfusion requirements during the intraoperative period. This study includes 595 patients who underwent open surgery for hip dysplasia, including 297 (52.6%) classified as developmental dysplasia (DD) and 268 (47.3%) as neuromuscular (NM) with a mean age of 9.1 years (interquartile range 3-14). Intraoperative allogeneic transfusion was identified in 26/297 (8.8%) DD and 73/268 (27.2%) NM patients. Adjusted factors associated with increased odds of intraoperative transfusion were NM (odds ratio [OR]=2.96, 95% confidence interval [CI] [1.76, 5.00]) and the number of osteotomies performed (OR=1.82/osteotomy, 95% CI [1.40, 2.35]). Adjusted factors that reduced the odds of transfusion were the use of antifibrinolytics (OR=0.35, 95% CI [0.17, 0.71]) and regional anaesthesia (OR=0.52, 95% CI [0.29, 0.94]). For children undergoing surgery for hip dysplasia, the number of osteotomies performed is predictive of the need for allogeneic blood transfusion. Antifibrinolytics and regional anaesthesia are associated with reduced risk for allogeneic blood transfusion. Blood management initiatives, such a preoperative optimization of haemoglobin and the use of antifibrinolytics, could target patients at increased risk of intraoperative bleeding and transfusion.

Intraoperative transfusion management, antifibrinolytic therapy, coagulation monitoring and the impact on short-term outcomes after liver transplantation-A systematic review of the literature and expert panel recommendations.

Liver transplantation (LT) is frequently complicated by coagulopathy associated with end-stage liver disease (ESLD), that is, often multifactorial. The objective of this systematic review was to identify evidence based intraoperative transfusion and coagulation management strategies that improve immediate and short-term outcomes after LT. PRISMA-guidelines and GRADE-approach were followed. Three subquestions were formulated. (Q); Q1: transfusion management; Q2: antifibrinolytic therapy; and Q3: coagulation monitoring. Sixteen studies were included for Q1, six for Q2, and 10 for Q3. Q1: PRBC and platelet transfusions were associated with higher mortality. The use of prothrombin complex concentrate (PCC) and fibrinogen concentrate (FC) were not associated with reductions in intraoperative transfusion or increased thrombotic events. The use of cell salvage was not associated with hepatocellular carcinoma (HCC) recurrence or mortality. Cell salvage and transfusion education significantly decreased blood product transfusions. Q2: Epsilon-aminocaproic acid (EACA) and tranexamic acid (TXA) were not associated with decreased blood product transfusion, improvements in patient or graft survival, or increases in thrombotic events. Q3: Viscoelastic testing (VET) was associated with decreased allogeneic blood product transfusion compared to conventional coagulation tests (CCT) and is likely to be cost-effective. Coagulation management guided by VET may be associated with increases in FC and PCC use. Q1: A specific blood product transfusion practice is not recommended (QOE; low | Recommendation; weak). Cell salvage and educational interventions are recommended (QOE: low | Grade of Recommendation: moderate). Q2: The routine use of antifibrinolytics is not recommended (QOE; low | Recommendation; weak). Q3: The use of VET is recommended (QOE; low-moderate | Recommendation; strong).

Global Current Practice Patterns for the Management of Hyphema.

PurposeHyphema is a sequela of ocular trauma and can be associated with significant morbidity. Management of this condition is variable and can depend on individual institutional guidelines. We aimed to summarize current practices in hyphema management across ophthalmological institutions worldwide.MethodsA cross-sectional online survey was conducted across North America, Asia, South America, Africa, Europe, and Australia from August 2020 to January 2021. The survey assessed the existing practices in the management of hyphema at each institution.ResultsFor layered hyphema, topical steroids were routinely administered by 34 (of 36 respondents, 94.4%) institutions, of which prednisolone was the preferred choice (n = 32, 88.9%). Topical cycloplegics were used at 34 (94.4%) institutions. No institution reported routine use of antifibrinolytics. Head elevation was the most deployed procedure to promote hyphema reabsorption (n = 31, 86.3%), followed by partial bed rest (n = 21, 58.3%). The majority of institutions (n = 25, 69.4%) did not routinely pursue admission for hyphema patients, although 75.0% of institutions (n = 27) scheduled follow-up visits within 48 hours of presentation. Additionally, few institutions performed routine sickle cell trait testing for patients presenting with hyphema (n = 6, 16.7%). The decision to perform anterior chamber washout varied and was often based on intraocular pressure and the speed of hyphema resolution.ConclusionUnanimity of international institutions on hyphema management is lacking. As it stands, many current interventions have unconvincing evidence supporting their use. Evidence-based guidelines would be beneficial in guiding decision-making on hyphema management. Additionally, areas of consensus can be used as foundations for future standard of care investigations.

Prophylactic Use of Antifibrinolytics During Pediatric Cardiac Surgery With Cardiopulmonary Bypass on Postoperative Bleeding and Transfusion: A Systematic Review and Meta-Analysis.

To determine the effect of intraoperative antifibrinolytics, including tranexamic acid (TXA), aminocaproic acid (EACA), or aprotinin, on bleeding in children undergoing cardiac surgery with cardiopulmonary bypass (CPB). Relevant articles were systematically searched from Ovid MEDLINE, Ovid EMBASE, CINAHL, Cochrane Library, and Web of Science to November 15, 2021. Abstracts were screened, and full texts were reviewed using predetermined inclusion and exclusion criteria using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. A standardized data extraction tool was used. Sixty-eight studies including 28,735 patients were analyzed. TXA compared with placebo resulted in a mean decrease in chest tube output of 9.1 mL/kg (95% CI, 6.0-12.3 mL/kg), I2 equals to 65.2%, p value of less than 0.001, platelet requirement of 2.9 mL/kg (95% CI, 0.1-5.8 mL/kg), I2 =72.5%, p value less than 0.001 and plasma requirement of 4.0 mL/kg (95% CI, 0.6-7.2 mL/kg), I2 equals to 94.5%, p value less than0.001. Aprotinin compared with placebo resulted in a mean decrease in chest tube output of 4.3 mL/kg (2.4-6.2 mL/kg), I2 equals to 66.3%, p value of less than 0.001, platelet transfusion of 4.6 mL/kg (95% CI, 0.6-8.6 mL/kg), I2 equals to 93.6%, p value of less than 0.001, and plasma transfusion of 7.7 mL/kg (95% CI, 2.1-13.2 mL/kg), I2 equals to 95.3%, p value of less than 0.001. EACA compared with placebo resulted in a mean decrease in chest tube output of 9.2 mL/kg (2.3-21.0 mL/kg), I2 equals to 96.4%, p value of less than 0.001, RBC transfusion of 7.2 mL/kg (95% CI, 2.4-12.1 mL/kg), I2 equals to 94.5%, p value equals to 0.002, and platelet transfusion of 10.7 mL/kg (95% CI, 2.9-18.5 mL/kg), I2 equals to 0%, p value of less than 0.001. No statistical difference was observed in chest tube output when TXA was compared with aprotinin. Subgroup analysis of cyanotic patients showed a significant decrease in chest tube output, platelet requirement, and plasma requirement for patients receiving aprotinin. Overall, the quality of evidence was moderate. Antifibrinolytics are effective at decreasing blood loss and blood product requirement in children undergoing cardiac surgery with CPB although the quality of evidence is only moderate.

Blood Conservation in Anaesthesia and Surgery - A Review

Dangers to blood transfusion exist even when stringent methods are used to screen blood before transfusion. These dangers include blood transfusion reactions and the transmission of bacteria, viruses and protozoa to patients. Blood conservation adopts strategies that restrict the transfusion of homologous blood to patients. Conservation starts in the preoperative period and includes the diagnosis and management of anaemia. Augmentation of the preoperative haemoglobin can be achieved by using a combination of iron preparations, vitamins, protein supplementation, erythropoietin and treatment for malaria in suspected patients. Maintenance of the intravascular volume during surgery can be achieved using colloids and crystalloids. Blood conservation techniques, including induced hypotension, use of anti-fibrinolytics and acceptable forms of autologous blood transfusion reduce the need for allogeneic blood transfusion. Blood conservation methods are also important in critically ill patients and includes, accepting lower haemoglobin levels, restricting the amount of blood taken during phlebotomy and the use of erythropoietin/erythropoietin receptor agonists.