vitamin-k-semiquinone-radical and Blood-Loss--Surgical

Catheter ablation for atrial fibrillation (AF) is associated with a transitory increase in the risk of both thromboembolic and bleeding events. Evidence on the use of nonvitamin K antagonist oral anticoagulants (NOACs) in patients undergoing AF ablation mostly comes from small observational studies, underpowered to detect differences in clinical outcomes between NOACs and vitamin K antagonists (VKAs) treated patients. This updated meta-analysis aimed to determine the safety and efficacy of periprocedural anticoagulation with NOACs compared with VKAs in AF patients undergoing catheter ablation.. We searched MEDLINE, Cochrane library, and web sources for randomized and observational studies comparing periprocedural treatment with NOACs and VKAs in patients undergoing AF ablation. The primary safety endpoint was major bleeding events, and the primary efficacy endpoint was thromboembolic events (a composite of systemic thromboembolism, transient ischemic attack, and stroke).. Use of NOACs compared to VKAs significantly reduced the risk of bleeding in patients with AF ablation. Similarly, the risk of bleeding was lower with uninterrupted NOACs than with uninterrupted VKAs, and with interrupted NOACs than with interrupted VKAs. The rate of thromboembolic complications was extremely low in both study groups without any differences.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Blood Loss, Surgical; Catheter Ablation; Drug Administration Schedule; Humans; Patient Safety; Postoperative Hemorrhage; Risk Assessment; Risk Factors; Treatment Outcome; Venous Thromboembolism; Vitamin K

Many patients under oral anticoagulation therapy need percutaneous or surgical interventions/operations. For vitamin K antagonists (VKA), there are recommendations regarding preoperative or postoperative administration. Management of the new oral anticoagulants (NOAC) was supposed to be easier - but some aspects must be considered. Due to the different pharmacokinetic profiles of substances such as dabigatran, rivaroxaban, apixaban, and edoxaban, different recommendations are given.Upon periprocedural management, thromboembolic risk has to be considered in patients treated with NOACs. NOACS have a pharmacokinetic advantage in terms of a rapid onset and rapid elimination via the liver and kidneys. Impaired renal function results in extended half-life of NOACs considerably.Surgical procedures under NOACS can be scheduled at the beginning of next dosing interval or omitted in low/minimal bleeding risk patients, so that only 2-3 NOAC doses are not administered. In patients with moderate and high risk of bleeding, there should be a NOAC break of 24-48 h prior to surgery in order to allow a corresponding decay of the active metabolite. In patients with low/intermediate risk for thromboembolism, no bridging is necessary if the "unprotected" time (NOAC break) is less than 4-5-(7) days. In patients at high risk of thromboembolism, individual consideration must be taken regarding bridging or extended NOAC break. Whether NOACs can be dispensed or bridging is necessary in these patients must be clarified in randomized trials for periprocedural management of NOACs patients.

Topics: Administration, Oral; Antibodies, Monoclonal, Humanized; Anticoagulants; Blood Loss, Surgical; Dabigatran; Drug Interactions; Half-Life; Humans; Pyrazoles; Pyridines; Pyridones; Rivaroxaban; Surgical Procedures, Operative; Thiazoles; Thromboembolism; Vitamin K

Regarding thromboembolic events, non-vitamin K antagonists, so-called new oral anticoagulative agents (NOACs), have widely enlarged prophylaxis and therapy. In contrast to vitamin K antagonists they can be administered in a definite dose and do not need any regular control of coagulation parameters. Thus being simple in handling, these drugs have become enormously attractive for both patient and physician.In spite of all their advantages NOACs have to be considered carefully. They have a significant disadvantage: the plasma concentration is not detectable by a simple blood test, nor is there any antidote available. As a consequence the bleeding risk remains unknown.In this review we focus on two different settings in routine surgical work: the preoperative management of patients undergoing elective surgery differs significantly from that needed in urgent surgery.

Topics: Administration, Oral; Aged, 80 and over; Antibodies, Monoclonal, Humanized; Anticoagulants; Blood Coagulation; Blood Loss, Surgical; Fatal Outcome; Female; Hemangioma; Hemorrhage; Humans; Liver Neoplasms; Perioperative Care; Risk Factors; Surgical Procedures, Operative; Thromboembolism; Vitamin K

Topics: Administration, Oral; Anticoagulants; Blood Coagulation Tests; Blood Loss, Surgical; Humans; Medication Therapy Management; Perioperative Care; Vitamin K

Oral anticoagulation is a widely used treatment and atrial fibrillation (AF) is the most frequent indication. We review the therapeutic options on an important clinical challenge: rapid reversal anticoagulation in the setting of an urgent invasive procedure. We report a case of a 71-year-old man treated with warfarin who was over-anticoagulated when presented to the emergency department for syncope due to severe bradiarrhythmia and needed temporary pacing. Intravenous infusion of vitamin-k was not adequate for rapid reversal over anticoagulation whereas the administration of a Prothrombin Complex Concentrate (PCC) was able to quickly reverse anticoagulant activity and allowed the performance of an urgent invasive procedure without hemorrhagic complication. The aim of this paper is to draw attention to possible therapeutic strategies to reduce the risk of bleeding related to over-anticoagulation with vitamin-K antagonists (VKAs) in case of urgent invasive procedure, emphasizing the role of PCC in keeping with national and international guidelines.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Blood Coagulation Factors; Blood Loss, Surgical; Humans; Male; Pacemaker, Artificial; Vitamin K; Warfarin

Prothrombin complex concentrates (PCCs) are purified drug products with hemostatic activity derived from a plasma pool. Today, PCCs contain a given and proportional amount of four non-activated vitamin K-dependent coagulation factors (II, VII, IX, and X), a variable amount of anticoagulant proteins (proteins C and S, and in some antithrombin) and low-dose heparin. In some countries PCC products contained only three clotting factors, II, IX, and X. Dosage recommendations are based on IU of F-IX, so that one IU of F-IX represents the activity of F-IX in 1 mL of plasma. Reversion of the anticoagulant effect of vitamin K antagonists (VKAs) in cases of symptomatic overdose, active bleeding episodes, or need for emergency surgery is the most important indication for PCCs and this effect of PCCs appears to be more complete and rapid than that caused by administration of fresh frozen plasma. They may be considered as safe preparations if they are used for their approved indications at the recommended dosage with adequate precautions for administration, and have been shown to be effective for reversing the effect of VKAs. Their adequate use based on decision algorithms in the perioperative setting allows a rapid normalization of International Normalized Ratio (INR) for performing emergency surgery, minimizing bleeding risk. This review aims to propose two algorithms for the use of PCCs in the perioperative setting, one to calculate the PCCs dose to be administered in a bleeding patient and/or immediately before urgent surgery, based on patient's clinical status, prior INR and INR target and another for reversing the action of oral anticoagulants depending on urgency of surgery.

Topics: Algorithms; Anticoagulants; Antidotes; Blood Coagulation Factors; Blood Coagulation Tests; Blood Loss, Surgical; Disseminated Intravascular Coagulation; Drug Monitoring; Emergencies; Evidence-Based Medicine; Hemorrhage; Hemostatics; Humans; Liver Failure; Perioperative Care; Postoperative Hemorrhage; Randomized Controlled Trials as Topic; Thromboembolism; Vitamin K

On of the most common, and serious, complications in cardiac surgery is postoperative bleeding. According to the majority of studies, between 10% and 92% of patients subjected to elective surgery require transfusions of blood products and blood derivatives. Transfusions and reinterventions are associated with longer stays in critical care units and a decrease in survival rates. There have been some important changes in the treatment of changes in haemostasis and post-surgical bleeding in the last few years, particularly with the introduction into clinical practice of working procedures backed up by clinical guidelines, as well as the appearance of new drugs. The aim of this work is to describe the main characteristics and update the use of prothrombin complexes that are currently available in Spain, with special emphasis on their use in cardiac surgery.

Topics: Anticoagulants; Blood Coagulation Factors; Blood Loss, Surgical; Blood-Borne Pathogens; Cardiac Surgical Procedures; Contraindications; Disease Transmission, Infectious; Drug Contamination; Drug Costs; Heart Diseases; Hemorrhagic Disorders; Hemostatics; Humans; Postoperative Hemorrhage; Preanesthetic Medication; Thrombophilia; Thrombosis; Vitamin K

Different guidelines exist regarding the prevention of venous thromboembolism (VTE) in orthopedic surgery.. We aimed to compare (inter)national guidelines and analyse differences.. MEDLINE, the Cochrane Library and the internet were searched for guidelines on the prevention of VTE in orthopedic surgery. From these, we constructed a table comparing the different antithrombotic regimens during different orthopedic surgical and plaster cast treatments.. Eleven guidelines from nine different countries and one international guideline were included. Few guidelines advise on thrombosis prophylaxis after plaster cast immobilization, (prolonged) arthroscopic surgery and isolated lower extremity trauma. Different opinions exist on the sole use of aspirin and mechanical prophylaxis and on the use of vitamin K antagonists after major hip and knee surgery.. Based on the same available literature, different guidelines recommend different thromboprophylactic regimens. Ideally, the grade of recommendation should be based on the same level of evidence world-wide. Whilst there is no agreement on the relevance of different endpoints (e.g. asymptomatic DVT), it is very difficult to reach a consensus. Thromboprophylaxis guidelines should be reviewed and updated on a regular basis, because the evidence is evolving rapidly.

Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Blood Loss, Surgical; Casts, Surgical; Evidence-Based Medicine; Fibrinolytic Agents; Guideline Adherence; Heparin; Hip Fractures; Humans; Knee; Lower Extremity; Orthopedic Procedures; Postoperative Hemorrhage; Practice Guidelines as Topic; Practice Patterns, Physicians'; Thrombosis; Treatment Outcome; Vitamin K

The purpose of this article is to review the effective options for the reversal of vitamin K antagonists (warfarin and it coumarin analogues) and to help identify the option best suited for the patient requiring urgent surgery.. Vitamin K antagonists, the mainstay in long-term anticoagulation therapy, can be reversed with the administration of vitamin K, frozen plasma (FP), recombinant factor VIIa (rFVIIa), or the recently approved four-factor prothrombin complex concentrate (PCC), Octaplex. While there is little evidence to suggest a superiority of PCC over FP, the availability of PCC in Canada is an important therapeutic addition requiring a thorough understanding of its pharmacology and risk benefit profile for the reversal of vitamin K antagonists. The use of PCC in the management of microvascular bleeding should be limited to very specific indications and should not be indicated in the routine management of massive blood loss.. In order to limit the blood loss associated with surgery and the management of uncontrolled bleeding, PCC is an important addition to our therapeutic armamentarium in the reversal of vitamin K antagonists.

Topics: Animals; Anticoagulants; Antidotes; Antifibrinolytic Agents; Blood Coagulation Factors; Blood Loss, Surgical; Coumarins; Hemorrhage; Humans; Vitamin K; Warfarin

Patients undergoing oral anticoagulation treatment with vitamin K antagonist (VKA) therapy are at a high risk of bleeding when undergoing an invasive surgery or procedure. Bridging therapy with parenteral heparin, usually at therapeutic doses, aims to protect these patients against thromboembolism during temporary periprocedural interruption of VKA therapy. Whether or not to interrupt VKA therapy and initiate bridging therapy is a difficult decision that is based upon both the patient's and the procedure's thromboembolic and bleeding risks.. There are minor procedures that can safely be done without the need for VKA interruption. Patient groups that may benefit from bridging therapy during temporary VKA interruption for a procedure include those who are at moderate-to-high risk of thromboembolism. Procedural bleed risk should determine when to resume bridging and VKA therapies. Recent findings highlight that low-molecular-weight heparin, usually in the outpatient setting, is the preferred agent over intravenous unfractionated heparin for bridging therapy, which includes patients with prosthetic heart valve indications for VKA therapy.. Large, recently initiated placebo-controlled trials in bridging therapy are discussed, as well as future alternatives to VKA therapy in oral anticoagulation during the periprocedural period.

Topics: Administration, Oral; Anticoagulants; Blood Loss, Surgical; Drug Administration Schedule; Heparin, Low-Molecular-Weight; Humans; Preoperative Care; Vitamin K; Warfarin

The present report from several French medical societies in the field and the French National Authority for Health provides an expert consensus for the management of patients on vitamin K antagonists in at-risk situations (overdose, risk of bleeding, and active bleeding). Asymptomatic VKA overdose is defined as an International Normalized Ratio (INR) value above the upper limit of the therapeutic target. In this case, the guidelines describe the rapid reduction of the INR down to the therapeutic range, either by omitting a dose or using vitamin K. Regarding the haemorrhagic complications, the guidelines address the management of these patients according to the severity of bleeding, and especially focus on the use of prothrombin complex concentrate. Finally, the consensus addresses the management of patients in cases of elective or emergency surgery or other invasive procedures, and discusses whether treatment should be continued or not, and whether VKA substitution by heparin--"bridging anticoagulation"--is needed.

Topics: Anticoagulants; Blood Coagulation; Blood Coagulation Factors; Blood Loss, Surgical; Coagulants; Drug Overdose; Elective Surgical Procedures; Hemorrhage; Heparin; Humans; International Normalized Ratio; Postoperative Hemorrhage; Risk Assessment; Risk Factors; Societies, Medical; Vitamin K

Oral anticoagulation (OAC) with vitamin K antagonists is commonly used for long-term prevention or treatment of arterial or venous thromboembolism. In the USA alone, approximately 250,000 patients will require temporary interruption of OAC annually. Managing anticoagulation in those patients on chronic OAC who require invasive procedures continues to be a major clinical dilemma. This article summarizes the existing evidence in light of the recommendations of the American College of Chest Physicians. Management of anticoagulation in the perioperative period will continue to be an important clinical challenge and an evolving area of research. If new oral anticoagulants are successful in replacing warfarin, the entire perioperative anticoagulation scene will change.

Topics: Administration, Oral; Anticoagulants; Blood Loss, Surgical; Evidence-Based Medicine; Heparin; Humans; Perioperative Care; Practice Guidelines as Topic; Risk Factors; Venous Thromboembolism; Vitamin K

Clinicians, including anesthesiologists, surgeons, and intensivists, are frequently called on to correct coagulopathy in patients receiving oral anticoagulation therapy. Before elective surgery, anticoagulation reversal may be undertaken over several days by discontinuing warfarin or vitamin K treatment, but rapid correction is required in an emergency. European and American guidelines recommend prothrombin complex concentrates (PCCs) for anticoagulation reversal in patients with life-threatening bleeding and an increased international normalized ratio. Compared with human fresh frozen plasma, PCCs provide quicker correction of the international normalized ratio and improved bleeding control. Although there are historic concerns regarding potential infectious and thrombotic risks with PCCs, current PCC formulations are much improved. Recombinant activated factor VII is a potential alternative to PCCs, but preclinical comparisons suggest that PCCs are more effective in correcting coagulopathy. Although many patients who require rapid reversal of warfarin are currently treated with fresh frozen plasma, PCCs should be considered as an alternative therapy.

Topics: Blood Coagulation; Blood Coagulation Factors; Blood Loss, Surgical; Disease Management; Hemostatics; Humans; International Normalized Ratio; Perioperative Care; Vitamin K; Warfarin

Vitamin K deficiency leads to a deficit in vitamin K-dependent factors, resulting in either hypocoagulability and a decrease in the Quick one-stage prothrombin time expressed as the prothrombin time (PT), or in an increase in INR in patients receiving oral anticoagulation. The anesthesiologist's objective is to bring these values back into the safety range before surgery, i.e., above 50% for PT and below 1.5 for INR. The method to be used will be chosen according to the urgency of the correction. Safety ranges may be reached in 6-12 h following oral or parenteral administration of vitamin K. A 5-mg dose is usually sufficient. If the deficit in vitamin K-dependent factors requires immediate correction, intravenous administration of PPSB should be done. The minimum time during which antivitamin K treatment may be disrupted after surgery depends on both the possibility of restarting oral treatment and the risk of postoperative haemorrhage. During this period, the need for an anticoagulation treatment using heparin should be discussed according to the risk of thrombosis.

Topics: Blood Loss, Surgical; Coagulants; Humans; Risk Factors; Vitamin K; Vitamin K Deficiency

Anticoagulants (unfractionated heparin UFH, low-molecular-weight heparins LMWH, coumarins) are mainly used to prevent (prophylactic dosage) or treat (therapeutic dosage) deep-vein thrombosis and pulmonary embolism. After surgery, prophylactic regimens of UFH and LMWH induce a doubling of the hemorrhagic risk which is observed under placebo. At therapeutic dosages, UFH and LMWH are associated with a risk of major bleeding of about 5%, with a trend favouring LMWH for a similar antithrombotic efficacy. At therapeutic levels, coumarins induce major bleeding at a rate of approximately 1%/month. This figure is proportional to the duration and the intensity (INR) of the treatment. It appears to be the major determinant of an optimal duration of anticoagulant treatment following deep-vein thrombosis.

Topics: 4-Hydroxycoumarins; Anticoagulants; Blood Loss, Surgical; Contraindications; Hemorrhage; Heparin; Humans; Indenes; Pulmonary Embolism; Risk Factors; Thrombophlebitis; Vitamin K

To quantify thromboembolic and bleeding events in patients with low thromboembolic risk, who were chronically receiving vitamin K antagonists and undergoing elective surgery.. A descriptive, prospective, single-center study was conducted between December 2010 and July 2014. Patients aged over 18 years old, chronically anticoagulated with vitamin K antagonists and admitted for elective surgery were included in the study. We excluded patients with a creatinine clearance<30ml/min, a body weight>120kg, heparin-induced thrombocytopenia, pregnant women, carriers of an epidural catheter for analgesia, patients who underwent unscheduled surgery and high thromboembolic risk-patients. Vitamin K antagonists were discontinued 5 days prior to the procedure without administering anticoagulant enoxaparin. The NIR was measured 24h before the procedure. A single dose of 3mg of vitamin K was administered in cases of a NIR>1.5. Vitamin K antagonists was resumed according to the surgical bleeding risk. Events were registered between 5 days prior to the procedure until 30 days after it.. A total of 75 procedures were included in the study. Fifty-six patients (74.7%) received vitamin K antagonists for atrial fibrillation, 15 suffered from venous thromboembolism (20%) and 4 had mechanical heart valves (5.3%). Twenty-six patients (34.5%) underwent high-bleeding risk surgeries and 49 (65.5%) underwent low risk procedures. No thromboembolic event was recorded. Four bleeding events (5.3%) were reported, 3 of which were considered major bleeding events (2 fatal).. Suspending vitamin K antagonists with no bridging therapy performed in patients with a low thromboembolic risk does not expose such patients to a significant risk of embolic events.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Drug Administration Schedule; Elective Surgical Procedures; Female; Humans; Longitudinal Studies; Male; Middle Aged; Perioperative Care; Postoperative Hemorrhage; Prospective Studies; Risk; Treatment Outcome; Venous Thromboembolism; Vitamin K

Rapid reversal of vitamin K antagonist (VKA)-induced anticoagulation is often necessary for patients needing urgent surgical or invasive procedures. The optimum means of VKA reversal has not been established in comparative clinical trials. We compared the efficacy and safety of four-factor prothrombin complex concentrate (4F-PCC) with that of plasma in VKA-treated patients needing urgent surgical or invasive procedures.. In a multicentre, open-label, phase 3b randomised trial we enrolled patients aged 18 years or older needing rapid VKA reversal before an urgent surgical or invasive procedure. We randomly assigned patients in a 1:1 ratio to receive vitamin K concomitant with a single dose of either 4F-PCC (Beriplex/Kcentra/Confidex; CSL Behring, Marburg, Germany) or plasma, with dosing based on international normalised ratio (INR) and weight. The primary endpoint was effective haemostasis, and the co-primary endpoint was rapid INR reduction (≤1·3 at 0·5 h after infusion end). The analyses were intended to evaluate, in a hierarchical fashion, first non-inferiority (lower limit 95% CI greater than -10% for group difference) for both endpoints, then superiority (lower limit 95% CI >0%) if non-inferiority was achieved. Adverse events and serious adverse events were reported to days 10 and 45, respectively. This trial is registered at ClinicalTrials.gov, number NCT00803101.. 181 patients were randomised (4F-PCC n=90; plasma n=91). The intention-to-treat efficacy population comprised 168 patients (4F-PCC, n=87; plasma, n=81). Effective haemostasis was achieved in 78 (90%) patients in the 4F-PCC group compared with 61 (75%) patients in the plasma group, demonstrating both non-inferiority and superiority of 4F-PCC over plasma (difference 14·3%, 95% CI 2·8-25·8). Rapid INR reduction was achieved in 48 (55%) patients in the 4F-PCC group compared with eight (10%) patients in the plasma group, demonstrating both non-inferiority and superiority of 4F-PCC over plasma (difference 45·3%, 95% CI 31·9-56·4). The safety profile of 4F-PCC was generally similar to that of plasma; 49 (56%) patients receiving 4F-PCC had adverse events compared with 53 (60%) patients receiving plasma. Adverse events of interest were thromboembolic adverse events (six [7%] patients receiving 4F-PCC vs seven [8%] patients receiving plasma), fluid overload or similar cardiac events (three [3%] patients vs 11 [13%] patients), and late bleeding events (three [3%] patients vs four [5%] patients).. 4F-PCC is non-inferior and superior to plasma for rapid INR reversal and effective haemostasis in patients needing VKA reversal for urgent surgical or invasive procedures.. CSL Behring.

Topics: Aged; Analysis of Variance; Blood Coagulation Factors; Blood Loss, Surgical; Female; Hemostasis, Surgical; Hemostatics; Humans; International Normalized Ratio; Male; Plasma; Preoperative Care; Treatment Outcome; Vitamin K

VENTURE-AF is the first prospective randomized trial of uninterrupted rivaroxaban and vitamin K antagonists (VKAs) in patients with non-valvular atrial fibrillation (NVAF) undergoing catheter ablation (CA).. Trial size was administratively set at 250, the protocol-specified target. Events were independently and blindly adjudicated. We randomly assigned 248 NVAF patients to uninterrupted rivaroxaban (20 mg once-daily) or to an uninterrupted VKA prior to CA and for 4 weeks afterwards. The primary endpoint was major bleeding events after CA. Secondary endpoints included thromboembolic events (composite of stroke, systemic embolism, myocardial infarction, and vascular death) and other bleeding or procedure-attributable events. Patients were 59.5 ± 10 years of age, 71% male, 74% paroxysmal AF, and had a CHA2DS2-VASc score of 1.6. The average total heparin dose used to manage activated clotting time (ACT) was slightly higher (13 871 vs. 10 964 units; P < 0.001) and the mean ACT level attained slightly lower (302 vs. 332 s; P < 0.001) in rivaroxaban and VKA arms, respectively. The incidence of major bleeding was low (0.4%; 1 major bleeding event). Similarly, thromboembolic events were low (0.8%; 1 ischemic stroke and 1 vascular death). All events occurred in the VKA arm and all after CA. The number of any adjudicated events (26 vs. 25), any bleeding events (21 vs. 18), and any other procedure-attributable events (5 vs. 5) were similar.. In patients undergoing CA for AF, the use of uninterrupted oral rivaroxaban was feasible and event rates were similar to those for uninterrupted VKA therapy.. Clinicaltrials.gov trial registration number is NCT01729871.

Topics: Anti-Arrhythmia Agents; Atrial Fibrillation; Blood Loss, Surgical; Catheter Ablation; Drug Administration Schedule; Factor Xa Inhibitors; Female; Humans; Male; Middle Aged; Operative Time; Prospective Studies; Pulmonary Veins; Recurrence; Reoperation; Rivaroxaban; Single-Blind Method; Treatment Outcome; Vitamin K

Peri-procedural management of warfarin reflects an intricate balance between the restoration of haemostasis and appropriate thromboprophylaxis. This prospective single-arm study assessed the safety and efficacy of a convenient schedule, incorporating low-dose intravenous vitamin K (vitK(IV) ) for short-term warfarin reversal prior to elective surgery, as well as vitK-dependent factor levels (vitK-Factors) and International Normalized Ratio (INR) pre- and post-vitK(IV) . One seventy eight patients on long-term warfarin received 3mg vitK(IV) 12-18 h pre-procedure with no adverse reactions. 167/178 (94%) achieved an INR≤1·5 post-vitK(IV) on the day of surgery, while all achieved INR≤1·7. Four patients had procedure-associated major bleeding, but importantly had achieved a pre-procedure INR<1·5 and vitK-Factors >0·30iu/ml. No patient suffered a symptomatic thromboembolism during the 6-week follow-up. Median days to re-establish a therapeutic INR were 4 (range 2-11). VitK(IV) near normalized all vitK-Factors, with a uniform pattern of depletion and repletion in association with an increase and decrease in INR, respectively; and from the data, INR<1·5 correlated with vitK-Factors >0·30iu/ml. Low-dose vitK(IV) for short-term warfarin reversal was reliable and safe, and successfully lowered the INR to an acceptable level for planned surgery, with no excess of bleeding, thromboembolism, delayed discharge, or resistance to warfarin. The protocol was simple and convenient for both the patients and the healthcare institution.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Drug-Related Side Effects and Adverse Reactions; Elective Surgical Procedures; Female; Humans; International Normalized Ratio; Male; Middle Aged; Perioperative Care; Premedication; Preoperative Care; Treatment Outcome; Vitamin K; Warfarin

To corroborate results obtained in The Netherlands with PPSB-SD, showing a safe acute reversal of anticoagulation within 15 minutes of administration.. PPSB-SD is a concentrate prothrombin complex containing a relatively constant high level of vitamin K-dependant coagulation factors II, VII, IX and X. PPSB-SD was administered to 14 patients treated with oral anticoagulants, according the patient's weight, the initial and the target INR (< 2.0 for moderate haemorrhage and abdominal surgery, or < 1.5 for severe haemorrhage and cardio-vascular interventions). INR values were measured with the Coagucheck Pro (Roche Diagnostics) upon admission and at 15 minutes, 1, 3 and 5 hours after treatment, and confirmed by the hospitals' laboratory.. Within 15 minutes 11 patients out of 12 reached their INR target (data were missing for 2 patients). INR decreased rapidly, then remained stable for the next 5 hours. All patients had a favourable outcome: bleeding was stopped and no haemorrhage occurred during surgery. Only one adverse event was reported, but it was not related to the PPSB-SD treatment. No sign of disseminated intravascular coagulation was observed during this study. The administration of PPSB-SD along with vitamin K and dosed according to body weight and initial and target INR allowed for optimal reversal of anticoagulation, as no second infusion was necessary. The recommended dosing worked also very well for patients with high initial INR (9.2 to 22.8) who were brought down to normal values (0.9 to 1.1) within 15 minutes.. PPSB-SD can safely be used for the rapid reversal of anticoagulation as needed in emergency situations.

Topics: Abdomen; Administration, Oral; Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation Factors; Blood Loss, Surgical; Body Weight; Coagulants; Emergencies; Female; Follow-Up Studies; Gastrointestinal Hemorrhage; Hip Fractures; Humans; International Normalized Ratio; Male; Middle Aged; Time Factors; Treatment Outcome; Vitamin K

When warfarin is interrupted for surgery, low-molecular-weight heparin is often used as bridging therapy. However, this practice has never been evaluated in a large prospective study. This study was designed to assess the efficacy and safety of bridging therapy with low-molecular-weight heparin initiated out of hospital.. This was a prospective, multicenter, single-arm cohort study of patients at high risk of arterial embolism (prosthetic valves and atrial fibrillation with a major risk factor). Warfarin was held for 5 days preoperatively. Low-molecular-weight heparin was given 3 days preoperatively and at least 4 days postoperatively. Patients were followed up for 3 months for thromboembolism and bleeding. Eleven Canadian tertiary care academic centers participated; 224 patients were enrolled. Eight patients (3.6%; 95% CI, 1.8 to 6.9) had an episode of thromboembolism, of which 2 (0.9%; 95% CI, 0.2 to 3.2) were judged to be due to cardioembolism. Of these 8 episodes of thromboembolism, 6 occurred in patients who had warfarin deferred or withdrawn because of bleeding. There were 15 episodes of major bleeding (6.7%; 95% CI, 4.1 to 10.8): 8 occurred intraoperatively or early postoperatively before low-molecular-weight heparin was restarted, 5 occurred in the first postoperative week after low-molecular-weight heparin was restarted, and 2 occurred well after low-molecular-weight heparin was stopped. There were no deaths.. Bridging therapy with subcutaneous low-molecular-weight heparin is feasible; however, the optimal approach for the management of patients who require temporary interruption of warfarin to have invasive procedures is uncertain.

Topics: Anticoagulants; Arterial Occlusive Diseases; Aspirin; Atrial Fibrillation; Blood Loss, Surgical; Cohort Studies; Dalteparin; Elective Surgical Procedures; Feasibility Studies; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Intraoperative Complications; Postoperative Complications; Postoperative Hemorrhage; Premedication; Preoperative Care; Prospective Studies; Risk; Thromboembolism; Treatment Outcome; Vitamin K; Warfarin

Hip fracture is common in the elderly, many of whom are on anticoagulation. However, data are limited on outcomes with anticoagulation reversal in patients undergoing hip fracture surgery.. Adults ≥60 years old on oral anticoagulation who underwent hip fracture surgery at 21 hospitals in Northern California from 2006 to 2016 were identified through electronic databases. Outcomes were compared among patients treated and untreated with anticoagulation reversal preoperatively.. Of 1984 patients on oral anticoagulation who underwent hip fracture surgery, 1943 (97.9%) were on warfarin and 41 (2.1%) were on direct oral anticoagulants. Reversal agents were administered to 1635 (82.4%). Compared to a watch-and-wait strategy, patients receiving reversal agents were more likely to be white, male, comorbid, and with higher admission and preoperative international normalized ratios (P <0.001 for all comparisons). No difference for 30-day mortality was detected between reversal vs non-reversal (7.8% vs 6.0%, respectively; hazard ratio [HR], 1.30 [95% confidence interval (CI), 0.82-2.07]). For secondary outcomes, reversal was associated with higher risk of delirium (8.6% vs 4.9%, risk ratio [RR], 1.77 [95% CI, 1.08-2.89]) and increased mean length of stay (6.4 vs 5.8 days, P <0.05). After adjustment, associations were no longer significant for delirium (RR 1.60, 95% CI, 0.97-2.65) or length of stay (mean difference 0.08, 95% CI, -0.55-0.71). No associations were detected between reversal and other secondary outcomes.. No significant associations were found between reversal agents and 30-day mortality or other outcomes in patients on oral anticoagulation who underwent hip fracture surgery. Further investigation is needed.

Topics: Aged; Aged, 80 and over; Antibodies, Monoclonal, Humanized; Anticoagulants; Antifibrinolytic Agents; Arthroplasty, Replacement, Hip; Asian; Black or African American; Blood Coagulation Factors; Blood Loss, Surgical; Blood Transfusion; Cohort Studies; Delirium; Factor Xa Inhibitors; Female; Fracture Fixation, Internal; Hip Fractures; Hispanic or Latino; Humans; International Normalized Ratio; Length of Stay; Male; Mortality; Orthopedic Procedures; Plasma; Postoperative Complications; Postoperative Hemorrhage; Preoperative Care; Proportional Hazards Models; Retrospective Studies; Sex Factors; Vitamin K; Warfarin; White People

About one third of all patients with proximal femur fractures take oral anticoagulation like aspirin (ASS), direct platelet aggregation inhibitors like Clopidogrel and Ticagrelor (PAI), vitamin-K-antagonists like Warfarin (VKA) and direct oral anticoagulants like Rivaroxaban, Dabigatran and Apixaban (DOAC). The management and timing of fracture stabilization of these patients is a rising challenge in orthopedic trauma. Our objective was to determine the effect of oral anticoagulation on patients with proximal femur fractures, which received a proximal femur nail antirotation (PFNA) within 24 h after trauma.. A retrospective chart review of 327 patients (mean age 80 ± 13 years; 223 women and 104 men) with sub- or intertrochanteric fractures between January 2013 and December 2017 was performed. All patients underwent surgery in the first 24 h after admission. Solely patients without or with only one type of oral anticoagulation were included. There were 74 patients with ASS, 30 with PAI, 52 with DOAC and 25 with VKA medication. All patients taking VKA received high dose Vitamin K or coagulation factors to normalize INR prior to surgery. Primary outcome measures were transfusion rate and pre- and postoperative hemoglobin (Hb) difference. Secondary outcome measures were mortality and complications like infection, hematoma and acute cardiovascular events.. Patients undergoing treatment with DOAC had a 3.4-fold increased risk for intraoperative blood transfusion. The risk for blood transfusion for patients taking ASS, PAI or VKA did no differ from the control group. Patients without an intraoperative blood transfusion on oral anticoagulation showed no increase in pre- and postoperative Hb-difference compared with controls. Anticoagulation showed no significant effect on complication rates and mortality in patients operated within the first 24 h.. Early surgical care of proximal femur fractures is safe even in patients with anticoagulant medication. All patients should be preoperatively prepared for possibly intraoperative transfusion, especially patients on DOAC.

Topics: Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Blood Loss, Surgical; Female; Femoral Fractures; Fracture Fixation, Internal; Humans; Male; Middle Aged; Postoperative Hemorrhage; Preoperative Care; Retrospective Studies; Time Factors; Vitamin K

The strategies of perioperative bridging anticoagulation in orthopedic surgical patients during oral anticoagulation (OAC) therapy with vitamin K antagonists (VKA) vary from center to center.. The aim of this single-center study was to assess the risk of bleeding and thromboembolic events (TEs) in bridged patients on VKA who underwent orthopedic surgery due to trochanteric or hip fracture.. The retrospective study included 64 patients (mean age: 80 years) who received VKA for at least 3 months prior to orthopedic procedure. All subjects were bridged with enoxaparin (40 mg once a day). The control group (n = 69) comprised of age-, sexand procedure-matched patients operated on for the same indications, but with neither a history of VKA therapy nor perioperative bridging anticoagulation.. Severe postoperative bleeding occurred in 19 (29.7%) patients from the VKA group and in 13 (18.8%) controls (p = 0.16). Within the VKA group, intertrochanteric fractures (52.6%) and femoral neck fractures (47.4%) occurred more often in patients with bleeding than other lower extremity fractures (0%; p = 0.03). Severe adverse events (SAEs) were more common in the VKA group than in the controls (12.5% vs 1.5%; p = 0.01). Patients from the VKA group did not differ from the controls in the incidence of TEs (6.3% vs 8.9%; p = 0.31). No intrahospital mortality was documented.. Prophylactic administration of enoxaparin is a common strategy of bridging anticoagulation in a hospital setting. This approach does not seem to be associated with an increase in thromboembolic risk nor higher risk of bleeding in orthopedic patients who received VKA preoperatively.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Female; Heparin, Low-Molecular-Weight; Hip Fractures; Humans; Male; Perioperative Care; Retrospective Studies; Treatment Outcome; Venous Thromboembolism; Vitamin K

Surgery in patients on anticoagulants requires careful monitoring and risk assessment to prevent harm. Required interruptions of anticoagulants and deciding whether to use bridging anticoagulation add further complexity. This process, known as perioperative anticoagulant management (PAM), is optimised by using guidelines. Optimal PAM prevents thromboembolic and bleeding complications. The purpose of this study was to assess the reliability of PAM practice in Dutch hospitals. Additionally, the variations between hospitals and different bridging dosages were studied.. A multicentre retrospective patient record review.. Records from 268 patients using vitamin-K antagonist (VKA) anticoagulants who underwent surgery in a representative random sample of 13 Dutch hospitals were reviewed, 259 were analysed.. Our primary outcome measure was the reliability of PAM expressed as the percentage of patients receiving guideline compliant care. Seven PAM steps were included. Secondary outcome measures included different bridging dosages used and an analysis of practice variation on the hospital level.. Preoperative compliance was lowest for timely VKA interruptions: 58.8% (95% CI 50.0% to 67.7%) and highest for timely preoperative assessments: 81% (95% CI 75.0% to 86.5%). Postoperative compliance was lowest for timely VKA restarts: 39.9% (95% CI 33.1% to 46.7%) and highest for the decision to apply bridging: 68.5% (95% CI 62.3% to 74.8%). Variation in compliance between hospitals was present for the timely preoperative assessment (range 41%-100%), international normalised ratio testing (range 21%-94%) and postoperative bridging (range 20%-88%). Subtherapeutic bridging was used in 50.5% of patients and increased with patients' weight.. Unsatisfying compliance for most PAM steps, reflect suboptimal reliability of PAM. Furthermore, the hospital performance varied. This increases the risk for adverse events, warranting quality improvement. The development of process measures can help but will be complicated by the availability of a strong supporting evidence base and integrated care delivery regarding PAM.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Female; Guideline Adherence; Humans; International Normalized Ratio; Male; Middle Aged; Netherlands; Perioperative Care; Postoperative Complications; Reproducibility of Results; Retrospective Studies; Thromboembolism; Vitamin K

The aim of this investigation was to analyse "total blood loss" (TBL), "blood transfusion rate" (BT) and the "amount of transfused blood units" (BU) between the different primary shoulder arthroplasty (SA) types: reverse, anatomical and stemless. Only primary SA was included. Further goal was to identify risk factors for TBL, amount of BU and BT rate.. A retrospective charts analysis of patients who received primary SA for degenerative shoulder pathology in our institution between 2004 and 2016 was performed. The demographic data, co-morbidities, haemoglobin and hematocrit level, BT rate, amount of transfused BU etc. were collected. TBL was estimated. Linear regression, log-linear poisson regression and logistic regression were used to compare the outcomes TBL, amount of transfused BU and BT rate, respectively, between different prosthesis types.. Of 278 patients included in this study 209 received reverse, 57 anatomical and 12 stemless SA. Mean TBL was 392.7 ml in reverse, 394.6 ml in anatomical and 298.3 ml in stemless SA. The BT rate and mean amount of BU were, respectively, 14.4% and 0.32 in reverse and 8.77% and 0.23 in anatomical SA. None of the patients with stemless arthroplasty received BT. Significant risk factors for elevated TBL are operation time, higher BMI, male sex. Significant risk parameters for BT and higher amount of transfused BU are low BMI, cemented arthroplasty, coronary heart disease, ASA score > 2 and previous therapy with vitamin K antagonists.. Although there were little differences between the blood transfusion rates in reverse vs. anatomical arthroplasty, there was no difference in total blood loss between these different prosthesis types. None of the patients with stemless arthroplasty received blood transfusion. There are various risk factors affecting total blood loss and blood transfusion rate. However, risk parameters influencing blood transfusion may be different to them affecting total blood loss.

Topics: Aged; Arthroplasty, Replacement, Shoulder; Blood Loss, Surgical; Blood Transfusion; Body Mass Index; Coronary Disease; Female; Humans; Male; Middle Aged; Operative Time; Retrospective Studies; Risk Factors; Sex Factors; Vitamin K

In 2015 a new Hungarian guideline was published regarding dental treatment and management of anticoagulated patients in agreement of the Hungarian Association of Oral and Maxillofacial Surgeons and the Dental Implantology Association of Hungarian Dentists.. The aim of the authors was to evaluate the efficiency and safety of local hemostatic measures recommended by the guideline in anticoagulated patients.. In these patients, postoperative bleeding episodes were examined after dental and oral surgical treatments, retrospectively.. Overall 263 bleeding risk cases were treated; 138 patients with vitamin K antagonists, 97 patients with antiplatelet therapy and 6 patients with novel oral anticoagulants. Six patients (2.3%) had minor postoperative bleeding after the "one hour control", while one patient needed a night duty support (0.5%). In contrast, 86 patients who were treated in rural practices neglecting the guideline attended the night duty with postoperative bleeding (3 patients treated with vitamin K antagonists, 24 patients taking low molecular weight heparin, 30 patients receiving antiplatelet therapy and one patient on novel oral anticoagulant therapy.. The Hungarian guideline can be applied safely, without increasing the risk of postoperative bleeding, however, rural dental practices are frequently unprepared for these treatments. Orv. hetil., 2016, 157(43), 1722-1728.

Topics: Anticoagulants; Blood Loss, Surgical; Female; Fibrinolytic Agents; Humans; Hungary; Male; Oral Surgical Procedures; Postoperative Hemorrhage; Retrospective Studies; Thromboembolism; Tooth Extraction; Vitamin K

Topics: Blood Coagulation Factors; Blood Loss, Surgical; Female; Hemostatics; Humans; Male; Plasma; Vitamin K

Topics: Atrial Fibrillation; Blood Loss, Surgical; Catheter Ablation; Factor Xa Inhibitors; Female; Humans; Male; Rivaroxaban; Vitamin K

The authors present a proposal of dental treatment and management of anticoagulated patients and of patients on antiplatelet therapy, with the approval by the Hungarian Association of Oral and Maxillofacial Surgeons and by the Dental Implantology Association of Hungarian Dentists. This current guide was based on recent Hungarian and on several foreign national guidelines and considers significant publications from international literature.

Topics: Anticoagulants; Blood Loss, Surgical; Drug Administration Schedule; Fibrinolytic Agents; Hemorrhage; Humans; Hungary; Oral Surgical Procedures; Thromboembolism; Time Factors; Vitamin K

Topics: Anticoagulants; Antifibrinolytic Agents; Antithrombins; Aspirin; Blood Loss, Surgical; Blood Transfusion; Clopidogrel; Coagulants; Factor Xa Inhibitors; Fibrinolytic Agents; Hemostasis, Surgical; Heparin; Humans; Perioperative Care; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Risk Assessment; Ticlopidine; Vitamin K; Warfarin

Perioperative management of anticoagulants and antiplatelet agents is based on a compromise between the risk of hemorrhage induced by maintaining (or substituting for) them and the risk of thrombosis if they are discontinued. The hemorrhage risk in major spinal surgery is clear (50-81% incidence of transfusion), and the incidence of postoperative symptomatic spinal hematoma varies between 0.4% and 0.2% depending on whether low-molecular-weight heparin (LMWH) is prescribed postoperatively. The French Health Authority, in 2008, published guidelines on the management of patients treated with vitamin K antagonists. Treatment may be stopped without preoperative replacement in certain cases of atrial fibrillation or venous thromboembolic disease; otherwise, preoperative replacement by curative dose unfractionated heparin (UFH) or LMWH is recommended, with withdrawal early enough to avoid peroperative bleeding. Postoperative care should take account of hemorrhagic risk following surgery. The management of patients treated with antiplatelets is delicate, as maintenance is preferable in most of the situations in which they are prescribed (bare or active stenting, or secondary prevention of myocardial infarction, stroke or peripheral ischemia), although they are liable to increase the risk of perioperative hemorrhage, especially when associated to antithrombotic prophylaxis. If surgery cannot be performed under treatment continuation, the interruption should be as short as possible. New guidelines are presently being drawn up under the auspices of the French Health Authority. In both types of treatment, the strategy should be jointly determined by surgeon, anesthesiologist and cardiologist, to optimize individualized care taking account of each party's requirements, with the patient in the central role. The selected strategy should be clearly stated in the patient's file.. V.

Topics: Anticoagulants; Blood Loss, Surgical; Hemorrhage; Humans; Orthopedic Procedures; Perioperative Care; Platelet Aggregation Inhibitors; Postoperative Care; Practice Guidelines as Topic; Risk Assessment; Spine; Venous Thrombosis; Vitamin K

Combined deficiency of the vitamin K-dependent clotting factors (VKCFD) is a rare bleeding disorder involving defective gamma-carboxylation of coagulation factors II , VII, IX and X as well as natural anticoagulants protein C and protein S. The disease is characterized by a cluster of different, often life threatening, bleeding symptoms occurring both spontaneously and in a surgical setting. In the present paper we describe two different treatment modalities to be used both in a programmed surgical procedure and in an emergency scenario. As this disease is a natural model that resembles oral anticoagulation, our experience discloses a possible rationale in the use of recombinant activated FVII for warfarin reversal.

Topics: Adult; Biopsy; Blood Coagulation Disorders, Inherited; Blood Coagulation Tests; Blood Loss, Surgical; Factor VII; Factor VII Deficiency; Factor VIIa; Female; Gastroscopy; Hemostasis, Surgical; Homozygote; Humans; Mixed Function Oxygenases; Recombinant Proteins; Tooth Extraction; Vitamin K; Vitamin K Epoxide Reductases

Patients subjected to haemodilution during surgery are at increased risk of bleeding. We hypothesised that, in the acquired dilutional coagulopathy, insufficient haemostasis is due to either insufficient thrombin generation or insufficient fibrin clot formation. In tissue factor-activated plasmas from patients with coagulation deficiency, we measured time curves of thrombin generation and fibrin clot formation (thromboelastography). Investigated were in study A: 10 patients treated with vitamin K antagonist and five healthy subjects; in study B: 30 patients undergoing cardiopulmonary bypass (CPB) surgery and infused with on average 2,000 ml crystalloids and colloids (no major bleeding); in study C: 58 patients undergoing major general surgery, and transfused with >5,000 ml crystalloids, colloids and red cell concentrates, who experienced major bleeding and were post-transfused with fresh frozen plasma. The treatment with vitamin K antagonist led to a progressive reduction in thrombin generation but not fibrin clot formation. In CPB patients, plasma factor levels post-surgery were 53-60% of normal. This was accompanied by moderate reduction in both haemostatic processes. In plasmas from patients undergoing major surgery, factor levels were 38-41% of normal, and these levels increased after plasma transfusion. Taking preset thresholds for normal thrombin generation and fibrin clot formation, at least one of these processes was low in 88-93% of the patients with (persistent) bleeding, but only in 40-53% of the patients without bleeding. In conclusion, the ability of thrombin generation and fibrin clot formation is independently reduced in acquired dilutional coagulopathy, while minimal levels of both are required for adequate haemostasis.

Topics: Aged; Blood Coagulation; Blood Coagulation Disorders; Blood Loss, Surgical; Blood Transfusion; Crystalloid Solutions; Female; Fibrin; Hemodilution; Hemorrhage; Hemostasis; Humans; Isotonic Solutions; Kinetics; Male; Middle Aged; Perioperative Care; Postoperative Hemorrhage; Thrombin; Vitamin K

Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Blood Loss, Surgical; Casts, Surgical; Evidence-Based Medicine; Fibrinolytic Agents; Guideline Adherence; Heparin; Hip Fractures; Humans; Knee; Lower Extremity; Orthopedic Procedures; Postoperative Hemorrhage; Practice Guidelines as Topic; Practice Patterns, Physicians'; Treatment Outcome; Venous Thromboembolism; Vitamin K

Topics: Anticoagulants; Blood Loss, Surgical; Coumarins; France; Humans; Perioperative Care; Postoperative Hemorrhage; Practice Guidelines as Topic; Registries; Societies, Medical; Vitamin K

Attempts at reducing exposure to allogeneic transfusions, using blood conservation techniques such as controlled hypotension and normovolemic hemodilution, have met with mixed results and are not always practical in small infants. Recombinant human erythropoietin (RHE), a hormone that stimulates RBC production, increases the hematocrit when administered to infants. A retrospective chart review of all patients undergoing fronto-orbital advancement for craniosynostosis by the same plastic surgeon between January 2002 and December 2002 was conducted. A subgroup of patients (10/19) received RHE as a blood-conservation strategy. Transfusion requirements were lower in the RHE group (5/10) versus the control group (9/9). Total volume of blood products transfused was statistically lower in the RHE group (154 mL RHE group versus 421 mL control) (P < 0.03). RHE combined with blood-conservation techniques was associated with a decreased need for blood transfusion, thus exposing the patient to fewer risks associated with allogeneic transfusion.

Topics: Blood Loss, Surgical; Blood Transfusion; Craniofacial Dysostosis; Dietary Supplements; Erythropoietin; Hematocrit; Hemostatic Techniques; Humans; Infant; Iron; Recombinant Proteins; Vitamin K

Topics: Anticoagulants; Aspirin; Atrial Appendage; Atrial Fibrillation; Blood Loss, Surgical; Carotid Arteries; Dalteparin; Drug Administration Schedule; Elective Surgical Procedures; Filtration; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Intraoperative Care; Postoperative Care; Postoperative Complications; Postoperative Hemorrhage; Premedication; Stents; Thromboembolism; Thrombosis; Vitamin K; Warfarin

The purpose of this study was to validate a protocol for dental extraction in patients taking vitamin K antagonists without changing the treatment when the INR is lower than 2.8.. One hundred four extractions (96 patients) were performed during a 9 month period in patients taking vitamin K antagonists. Extraction was performed when the international normalized ratio (INR) was less than 2.8, otherwise, the treatment was modified until the desired INR was reached. Extractions were performed under para-apical and alveolar local anesthesia and sutured with hemostatic gauze.. Three patients developed postoperative bleeding requiring alveolar revision with local application of tranexamic acid and in one case use of a biological glue.. The following protocol can be proposed: ambulatory extraction under local anesthesia with an INR the day before extraction: the extraction is performed if the INR is<=2.8 using hemostatic gauze suture and tranexamic acid in case of persistent bleeding.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Blood Loss, Surgical; Child; Clinical Protocols; Dental Care for Chronically Ill; Female; Humans; International Normalized Ratio; Male; Middle Aged; Oral Hemorrhage; Phenindione; Retrospective Studies; Tooth Extraction; Tranexamic Acid; Vitamin K; Warfarin

Topics: Adult; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Child; Delivery, Obstetric; Female; France; Hemostatics; Humans; Plasma; Pregnancy; Vitamin K

Thirty-six patients were included in a retrospective study of the effect of pre-operative anticoagulant therapy on peri-operative blood loss and haemostatic changes after heart transplantation. Eleven patients (group H) had received intravenous heparin for at least 3 weeks before cardiac transplantation. Twelve patients (group P) had been transplanted when fully anticoagulated with phenprocoumon. A control group of 13 patients (group C) had undergone bypass grafting of their coronary arteries with no pre-operative anticoagulant therapy. Post-operative drainage from the chest drains was 700 ml (median) in group H, 425 ml in group P, and 360 ml in group C (group H vs. group C: P < 0.05). After heparinization for cardiopulmonary bypass, activated clotting time was 462 s (median) in group H, 1500 s in group P, and 727 s in group C (P < 0.003 vs. groups H and P). Post-operatively, patients in group P were given more units of fresh frozen plasma (median 2.5 units; P < 0.01), prothrombin complex concentrate (median 1000 I.U.; P < 0.05) and vitamin K (median 10 mg; P < 0.05) than groups H and C. Heart transplantation under full phenprocoumon therapy does not increase the likelihood of complications caused by peri-operative bleeding.

Topics: Adult; Aged; Blood Loss, Surgical; Blood Transfusion; Blood Transfusion, Autologous; Chest Tubes; Coronary Artery Bypass; Female; Heart Transplantation; Hemostasis, Surgical; Heparin; Humans; Injections, Intravenous; Male; Middle Aged; Partial Thromboplastin Time; Phenprocoumon; Prothrombin; Retrospective Studies; Vitamin K; Whole Blood Coagulation Time