vitamin-k-semiquinone-radical and Postoperative-Complications

In this analysis, we aimed to compare the efficacy and safety of dual therapy (DT) with a non-vitamin K oral anticoagulant (NOAC) and an adenosine diphosphate receptor antagonist (P2Y12 inhibitor) vs triple therapy (TT) with aspirin, a P2Y12 inhibitor and a vitamin K antagonist for the treatment of diabetes mellitus (DM) patients with co-existing atrial fibrillation (AF) following percutaneous coronary intervention (PCI).. Medical Literature Analysis and Retrieval System Online (MEDLINE), http://www.ClinicalTrials.gov, Excerpta Medical data BASE (EMBASE), Web of Science, Cochrane Central and Google Scholar were the searched databases. Studies that were randomized trials or observational studies comparing DT vs TT for the treatment of DM patients with co-existing AF following PCI were included in this analysis. The adverse cardiovascular outcomes and bleeding events were the endpoints. This meta-analysis was carried out by the RevMan version 5.4 software. Risk ratios (RR) with 95% confidence intervals (CI) were used to represent data and interpret the analysis.. A total number of 4970 participants were included whereby 2456 participants were assigned to the DT group and 2514 participants were assigned to the TT group. The enrollment period varied from year 2006 to year 2018. Our current results showed that major adverse cardiac events (RR: 1.00, 95% CI: 0.84-1.20; P = .98), mortality (RR: 1.08, 95% CI: 0.78-1.48; P = .66), myocardial infarction (RR: 1.02, 95% CI: 0.74-1.42; P = .90), stroke (RR: 0.94, 95% CI: 0.53-1.67; P = .84) and stent thrombosis (RR: 1.09, 95% CI: 0.56-2.10; P = .80) were similar with DT versus TT in these patients. However, the risks for total major bleeding (RR: 0.66, 95% CI: 0.54-0.82; P = .0001), total minor bleeding (RR: 0.74, 95% CI: 0.64-0.85; P = .0001), Thrombolysis in Myocardial Infarction (TIMI) defined major bleeding (RR: 0.58, 95% CI: 0.35-0.95; P = .03), TIMI defined minor bleeding (RR: 0.62, 95% CI: 0.42-0.92; P = .02), intra-cranial bleeding (RR: 0.34, 95% CI: 0.13-0.95; P = .04) and major bleeding defined by the International Society on Thrombosis and Hemostasis (RR: 0.68, 95% CI: 0.51-0.90; P = .008) were significantly higher with TT.. DT with a NOAC and a P2Y12 inhibitor was associated with significantly less bleeding events without increasing the adverse cardiovascular outcomes when compared to TT with aspirin, a P2Y12 inhibitor and a Vitamin K antagonist for the treatment of DM patients with co-existing AF following PCI. Hence, DT is comparable in efficacy, but safer compared to TT. This interesting hypothesis will have to be confirmed in future studies.

Topics: 4-Hydroxycoumarins; Aged; Aspirin; Atrial Fibrillation; Diabetes Mellitus; Diabetic Cardiomyopathies; Drug Therapy, Combination; Female; Hematologic Agents; Humans; Indenes; Male; Observational Studies as Topic; Percutaneous Coronary Intervention; Postoperative Complications; Purinergic P2Y Receptor Antagonists; Randomized Controlled Trials as Topic; Treatment Outcome; Vitamin K

Vitamin K, a fat-soluble vitamin, is involved in blood coagulation, bone mineralization, inhibition of vascular calcification, and regulation of numerous enzyme systems. Patients who undergo bariatric surgery (BS), especially procedures that involve a malabsorptive component, are prone to develop vitamin K deficiency (VKD). The causes of VKD include decreased absorptive surface areas, steatorrhea, bacterial overgrowth, marked reduction of carriers of vitamin K, decrease in vitamin K intake, and modifications of gut microbiota. Data on vitamin K status among BS patients are scarce and the strength of evidence supporting vitamin K supplementation is weak. Thus, this systematic review summarized the scientific literature on vitamin K and examined the status among patients before and after BS, as well as among pregnant women with a history of BS. A MEDLINE/Pubmed and Embase electronic search was performed. After a thorough screening of 204 titles, 19 articles were selected by 2 independent reviewers. Five studies on BS candidates (n = 750), 12 studies after BS (n = 1442), and 4 studies on pregnant woman after BS (n = 83, of them n = 7 from case reports) were included. Results of the current review suggest that patients who undergo major malabsorptive surgeries are at a higher risk of developing VKD and should be better monitored. At this point, it is still unclear whether supplementation of vitamin K is required, and what oral dose or vitamer type should be used to normalize serum levels after different types of bariatric procedures. It should be noted that the current protocols for VKD treatment are still experiential in these patients. It is also unknown at what intervals screening tests for vitamin K should be performed and what assay is most appropriate for screening purposes. Future studies are needed to answer these unresolved issues.

Topics: Adult; Aged; Bariatric Surgery; Female; Humans; Malabsorption Syndromes; Male; Middle Aged; Obesity, Morbid; Postoperative Complications; Pregnancy; Vitamin K; Vitamin K Deficiency; Young Adult

Several authors have reported the relationship between gastric cancer risk and vitamins. However, there are few reports on fat-soluble vitamins after gastrectomy for gastric cancer. Fat malabsorption and suppression of food intake after gastrectomy for gastric cancer have been previously documented. Because of fat malabsorption and suppression of food intake, a potential deficiency in fat-soluble vitamins, such as vitamins A, D, E, and K, has been readily suggested. In about 20 % of patients, the serum vitamin E levels were decreased. Indeed, vitamin E deficiency is a common complication after gastrectomy. Continuous vitamin E deficiency could develop from neurological symptoms, i.e., peripheral neuropathy, limb or truncal ataxia. The total cholesterol level is associated with the vitamin E levels. However, the serum vitamin A levels were decreased in only 1.8 % of patients. In total gastrectomy cases, the serum vitamin A level may readily decrease. In contrast, 1,25(OH)

Topics: Gastrectomy; Humans; Postoperative Complications; Stomach Neoplasms; Vitamin A; Vitamin A Deficiency; Vitamin D; Vitamin E; Vitamin E Deficiency; Vitamin K

Topics: Aged; Anticoagulants; Atrial Fibrillation; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Orthopedic Procedures; Platelet Aggregation Inhibitors; Postoperative Complications; Randomized Controlled Trials as Topic; Risk Assessment; Venous Thrombosis; Vitamin K

The aim of this network meta-analysis was to evaluate the comparative efficacy and safety of dabigatran, rivaroxaban, apixaban, interrupted vitamin K antagonist (I-VKA), and continuous VKA (C-VKA) in patients undergoing radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF).. PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched to identify clinical trials comparing dabigatran, rivaroxaban, or apixaban with I-VKA or C-VKA, or against each other, in AF patients undergoing RFCA. A network meta-analysis was conducted to directly and indirectly compare the efficacy and safety of competitive anticoagulation regimens with a Bayesian random-effects model.. A total of 39 studies enrolling 27,766 patients were included. C-VKA demonstrated significant superiority over I-VKA in reducing thromboembolic events (risk difference [RD] -0.0068, 95 % confidence interval [CI] -0.0106 to -0.0032) and major bleeding complications (RD -0.0044, 95 % CI -0.0098 to -0.0006). Rivaroxaban compared with I-VKA was associated with a lower risk of thromboembolism (RD -0.0073, 95 % CI -0.0134 to -0.0012), being at the best ranking position among all of the compared anticoagulation regimens in terms of both the efficacy and safety. None of the remaining comparisons reached statistically significant difference in the rate of thromboembolism or major bleeding.. The present study suggests that C-VKA is superior to I-VKA for AF patients undergoing RFCA. Rivaroxaban is the highest probability to be the optimal alternative to C-VKA among the three non-VKA oral anticoagulants in AF ablation.

Topics: Administration, Oral; Aged; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Causality; Comorbidity; Dabigatran; Female; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Pyrazoles; Pyridones; Risk Factors; Rivaroxaban; Thromboembolism; Treatment Outcome; Vitamin K

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Benzimidazoles; Dabigatran; Elective Surgical Procedures; Emergencies; Factor Xa Inhibitors; Hemorrhage; Humans; Kidney Diseases; Morpholines; Orthopedic Procedures; Postoperative Complications; Premedication; Pyrazoles; Pyridines; Pyridones; Randomized Controlled Trials as Topic; Risk; Rivaroxaban; Thiophenes; Thrombophilia; Vitamin K

New oral anticoagulants do represent a major step forward as compared to low molecular weight heparins and vitamin K antagonists. Several issues deserve attention regarding their perioperative management. Three (and very soon four or five) active molecules are available on the market, adding to the major intra- and inter-individual variability, to the high number of drug-drug interactions, and to the interferences of renal function and many other parameters. New tests are available including the diluted thrombin time for dabigatran and a specific anti-Xa test for rivaroxaban and apixaban. No antidote is approved yet. Scheduled surgery: the safest suggestion is to mimic the perioperative management of vitamin K antagonist, with a 5-day interruption and low molecular weight heparin bridging whenever necessary. Emergency procedures: several suggestions issued from the Groupe d'Intérêt en Hémostase Péri-opératoire are proposed.

Topics: Administration, Oral; Anticoagulants; Blood Coagulation Tests; Drug Administration Schedule; Drug Substitution; Heparin, Low-Molecular-Weight; Humans; Perioperative Care; Postoperative Complications; Postoperative Hemorrhage; Thromboembolism; Vitamin K

Topics: Administration, Oral; Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Cerebral Hemorrhage; Dabigatran; Gastrointestinal Hemorrhage; Humans; Intracranial Embolism; Morpholines; Postoperative Complications; Pyrazoles; Pyridones; Risk Factors; Rivaroxaban; Thiophenes; Thrombosis; Vitamin K; Warfarin

Anticoagulant drugs belong to the group of antithrombotic agents and are successfully used in the prophylaxis and treatment of thromboembolic disorders. The use of anticoagulants in the prevention of deep venous thrombosis has significantly lowered the risk of venous thrombosis and fatal pulmonary embolisms even in high-risk situations such as orthopedic surgery. Anticoagulants play a central role in the treatment of acute venous thrombosis and in the prevention of recurrent events. Long-term anticoagulation therapy with orally active anticoagulants significantly reduces the risk of thromboembolic complications in patients showing cardiac arrhythmias. Whereas a few years ago heparins and vitamin K antagonists were the dominant anticoagulants, today a wide range of anticoagulants with improved pharmacological profiles are available. It remains an open question whether these new anticoagulants will improve the efficacy, safety, and acceptance of anticoagulant treatment approaches.

Topics: Administration, Oral; Anticoagulants; Antithrombins; Arginine; Arrhythmias, Cardiac; Blood Coagulation Tests; Factor Xa Inhibitors; Hemorrhage; Heparin; Heparinoids; Hirudins; Humans; Infusions, Intravenous; Orthopedic Procedures; Peptide Fragments; Pipecolic Acids; Postoperative Complications; Pulmonary Embolism; Recombinant Proteins; Risk Factors; Secondary Prevention; Sulfonamides; Thromboembolism; Treatment Outcome; Venous Thrombosis; Vitamin K

Peripheral arterial occlusive disease is one manifestation of the systemic disease atherosclerosis. The initial therapy for every arteriosclerotic disease is aimed at reducing cardiovascular risk factors by lifestyle modification and medication. Patients who require surgical revascularisation need long-term antiplatelet therapy or anticoagulation. This therapy has to be differentiated according to the vascular territory involved and the method used for revascularisation. After local thrombendarterectomy, alloplastic bypass graft surgery of the aortic, aorto-iliac, aorto-femoral or femoro-popliteal region above the knee, long-term ASA 100 mg/d or clopidogrel 75 mg/d should be initiated. After alloplastic bypass grafting below the knee the combination of ASA 100 mg/d and clopidogrel 75 mg/d should be used. In contrast, after venous grafts the patency rate is improved by anticoagulation with vitamin K antagonists (INR 2-3), if there is a low risk of bleeding. If there is a contraindication to vitamin K antagonists, ASA 100 mg/d should be used. After revascularisation, a structured surveillance programme should be implemented aiming at controlling cardiovascular risk factors and monitoring the vascular state, as well as the anticoagulation and the antiplatelet therapy.

Topics: Aortic Diseases; Aspirin; Blood Vessel Prosthesis Implantation; Clopidogrel; Dose-Response Relationship, Drug; Drug Therapy, Combination; Endarterectomy; Evidence-Based Medicine; Femoral Artery; Fibrinolytic Agents; Follow-Up Studies; Humans; Iliac Artery; International Normalized Ratio; Peripheral Arterial Disease; Polyethylene Terephthalates; Polytetrafluoroethylene; Popliteal Artery; Postoperative Complications; Prosthesis Design; Ticlopidine; Veins; Vitamin K

In the developed world, an increasing number of patients receive therapy with vitamin K antagonists (VKA). This group of patients poses an additional challenge in the perioperative management of emergency surgery and trauma. The present review offers a detailed description of some treatment options for reversal of VKA therapy. Optimal treatment of the anticoagulated patient requires a well-balanced intervention securing a reduced risk of haemorrhagic surgical complications as well as optimal anticoagulation post-operatively without exposing the patient to an increased risk of thromboembolic complications. The following factors must be considered in VKA-treated patients scheduled for emergency surgery: (1) the indication for VKA therapy, including the risk of thromboembolic events when the International normalized ratio (INR) is reduced, (2) type of surgery, including the risk of haemorrhagic complications and (3) the pharmacodynamic/-kinetic profile of the therapy used to revert the VKA therapy. Therapeutic options for acute reversal of VKA therapy include: vitamin K, fresh frozen plasma (FFP), prothrombin complex concentrate (PCC) and perhaps activated recombinant factor VII. PCC is a relatively new drug in some European countries and clinical experience is limited compared with the use of FFP. Reversal of VKA anticoagulation with PCC is faster and more efficient compared with FFP, but there are currently no randomized studies demonstrating an improved clinical outcome.

Topics: Blood Coagulation Factors; Factor VIIa; Guidelines as Topic; Hemorrhage; Hemostatics; Humans; International Normalized Ratio; Plasma; Postoperative Complications; Risk; Thromboembolism; Vitamin K

Anticoagulant prophylaxis for preventing venous thrombembolism (VTE) is a worldwide established procedure in hip (HR) and knee replacement (KR) surgery, as well as in the treatment of femoral neck fractures (FNF). Different guidelines are available in the literature, with quite different recommendations. None of them is a multidisciplinary effort as the one presented. The Italian Society for Studies on Hemostasis and Thrombosis, the Italian Society of Orthopedics and Traumatology, the association of Orthopedic Traumatology of Italian Hospitals, together with the Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care have set down easy and quick suggestions for VTE prophylaxis in HR and KR surgery as well as in FNF treatment. This inter-society consensus statement aims at simplifying the grading system reported in the literature, and thus at improving its proper application. Special focus is given to fragile patients, those with high bleeding risk, and on those receiving chronic antiplatelet and vitamin K antagonists treatment. A special chapter is dedicated to regional anesthesia and VTE prophylaxis.

Topics: Anesthesia; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Consensus; Femoral Neck Fractures; Fibrinolytic Agents; Fondaparinux; Heparin, Low-Molecular-Weight; Humans; Orthopedic Procedures; Patient Safety; Polysaccharides; Postoperative Complications; Postoperative Hemorrhage; Risk; Stockings, Compression; Thrombosis; Venous Thromboembolism; Vitamin K

Vitamin K antagonists and heparins have been standard anticoagulation drugs over the past decades. They are effective and safe but they have several drawbacks which has led to the development of new oral anticoagulants. Dabigatran etexilate is a specific oral thrombin inhibitor and rivaroxaban and apixaban are oral inhibitors of factor Xa. These agents produce a predictable anticoagulant response after fixed-dose administration so that routine coagulation monitoring is unnecessary. Currently, dabigatran etexilate, rivaroxaban and apixaban are licensed for thromboprophylaxis after elective total hip or knee replacement surgery. Since august 2011, dabigatran etexilate is licensed for patients with atrial fibrillation, rivaroxaban will follow. However, indications will be expanded e.g. for therapy of venous thromboembolism. It is important to be aware of the pharmacokinetic and pharmacodynamic profiles of these new agents. The drugs considerably influence the global test of coagulation thus making an interpretation of test results difficult. Currently, there is a lack of suitable coagulation tests to monitor anticoagulation in emergency cases, such as bleeding. Specific antidotes are not yet available.

Topics: Administration, Oral; Antithrombins; Arthroplasty, Replacement, Hip; Atrial Fibrillation; Benzimidazoles; Blood Coagulation Tests; Critical Care; Dabigatran; Drug Approval; Factor Xa Inhibitors; Fibrinolytic Agents; Hemorrhage; Heparin; Humans; Morpholines; Postoperative Complications; Pyrazoles; Pyridines; Pyridones; Rivaroxaban; Thiophenes; Thrombophilia; Vitamin K

Current evidence-based guidelines provide recommendations for prophylaxis and treatment of venous thromboembolism (VTE) in a variety of surgical patients.. A systematic Ovid Medline search (from 1950 to the present) was conducted for relevant articles using the following search terms: "venous thromboembolism," "thrombophlebitis," "thromboembolism," "pulmonary embolism," "heparin," "low-molecular-weight heparin," "postoperative complications," and "anticoagulants.". Pharmacologic and mechanical approaches are available for VTE prophylaxis, including low-dose unfractionated heparin, low-molecular-weight heparin, vitamin K antagonists, fondaparinux, intermittent pneumatic compression devices, and graduated compression stockings. Permanent inferior vena cava filters are not recommended for primary VTE prophylaxis, although they do have a role in the prevention of pulmonary embolism in patients with recent VTE who cannot have surgery delayed. Retrievable inferior vena cava filters are under investigation for primary VTE prophylaxis in trauma patients. New anticoagulants that inhibit factor Xa and thrombin will soon be available for the prevention and treatment of VTE in surgical patients.

Topics: Anticoagulants; Contraindications; Heparin; Humans; Intermittent Pneumatic Compression Devices; Patient Care Team; Postoperative Complications; Practice Guidelines as Topic; Renal Insufficiency; Risk Factors; Stockings, Compression; Surgical Procedures, Operative; Venous Thromboembolism; Vitamin K

The recommendations for anticoagulation in over 80 years old patients are based on the thromboembolic/bleeding risk relation. They add to the published recommendations for the specific indications. Low-molecular-weight heparin (LMWH) is used to prevent thromboembolism postoperatively. Compression stockings and/or intermittent pneumatic compression are used if bleeding risk is very high. The dose is increased starting at day two if the thromboembolic risk is very high. Bleeding and thromboembolic risks are re-evaluted daily. The antithrombotic therapy is adjusted accordingly. Prophylaxis of thromboembolism in patients with acute illnesses and bedrest is performed according postoperative care. Two-thirds of therapeutic doses of low-molecular-weight heparin are used to treat acute venous thromboembolism. Reduced renal function (creatinine clearance <30 ml/ min for most LMWHs or <20 ml/min for tinzaparin) should result in a further reduction of dose. Intensity and duration of prophylaxis of recurrent events with vitamin K antagonist or LMWH in malignancy follow current or herein described recommendations. Patients with atrial fibrillation are treated with vitamin K antagonists adjusted to an INR of 2-3 for prophylaxis of embolism. Further details of anticoagulant therapy should be in agreement with the national or international recommendations.

Topics: Age Factors; Aged; Aged, 80 and over; Anticoagulants; Dose-Response Relationship, Drug; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Kidney Function Tests; Neoplasms; Postoperative Complications; Risk Factors; Secondary Prevention; Stockings, Compression; Thromboembolism; Vitamin K

Many years of practical use and intensive scientific research have allowed vitamin K antagonists to become a cornerstone of treatment of internal diseases. Nevertheless, limitations in pharmacokinetics and -dynamics of vitamin K antagonists and the availability of new drugs in regard to a targeted anticoagulation therapy ask for a new review of the situation. Proof of effectiveness for the perioperative prophylaxis of venous thrombosis after hip and knee replacement has already been achieved for the direct thrombin inhibitor dabigatran etexilate as well as for the factor Xa inhibitors rivaroxaban und apixaban compared to low molecular weight heparins. These new drugs are now also investigated in patients with internal diseases. For the long-term application (6 or 12 months) concerning the treatment of venous thrombosis and/or stroke prophylaxis in patients with atrial fibrillation data is already available for the direct thrombin inhibitor dabigatran etexilate. Depending on its dosage its effectiveness in comparison with vitamin K antagonists is equal or even better without disadvantages in safety. However, vitamin K antagonists will remain the standard oral anticoagulation until open questions regarding e.g. insufficient therapy adherence (with termination rates up to 20%) or problems with drug interactions of the new competitive products have been completely answered.

Topics: Anticoagulants; Antithrombin Proteins; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Atrial Fibrillation; Benzimidazoles; Dabigatran; Humans; Morpholines; Postoperative Complications; Pyrazoles; Pyridines; Pyridones; Rivaroxaban; Stroke; Thiophenes; Venous Thrombosis; Vitamin K

Heparins, either unfractionated or low-molecular-weight (UFH and LMWHs), and vitamin K antagonists (VKAs) are currently the anticoagulants of choice for the prevention of post-operative venous thromboembolism (VTE) and for the treatment of acute venous and arterial thromboembolism. While VKAs are widely used in the US, LMWHs are the standard of care in the EU. Although efficacious, these agents are associated with a number of drawbacks, such as the risk of heparin-induced thrombocytopenia, the need for frequent coagulation monitoring in the case of UFH and VKAs, and the parenteral mode of administration in the case of heparins, which can lead to problems associated with patient compliance. There is a need for new anticoagulants that overcome these limitations. Direct, small-molecule inhibitors of coagulation proteins targeting a single enzyme in the coagulation cascade - particularly thrombin or Factor Xa - have been developed in recent years. Two agents, the direct thrombin inhibitor dabigatran and the direct Factor Xa inhibitor rivaroxaban, have recently been approved in the EU and several other countries for the prevention of VTE after total hip or knee replacement surgery. Here we will review data that suggest that the antithrombin-independent mechanism of action of these agents, particularly that of direct Factor Xa inhibitors, leads to increased efficacy with similar safety profiles compared with the antithrombin-dependent heparins. Although the end of the heparins era is not to be expected, the new anticoagulants presented in this review potentially represent the future of anticoagulation.

Topics: Anticoagulants; Antithrombin III; Blood Coagulation Factors; Clinical Trials as Topic; Drug Design; Enzyme Inhibitors; Factor V; Factor Xa; Factor Xa Inhibitors; Hemorrhage; Heparin; Heparin, Low-Molecular-Weight; Humans; Molecular Weight; Postoperative Complications; Purpura, Thrombocytopenic, Idiopathic; Thrombophilia; Venous Thromboembolism; Vitamin K

The overall thromboembolic risk is the resultant of patient-related risk and surgical risk. The surgical risk is decreasing, especially with the introduction of new procedures (fast-track surgery). The value of prophylaxis has been firmly established. Mechanical prophylaxis is to be used as first-line prophylaxis when there is a risk of bleeding. Combining this with drugs increases the antithrombotic efficacy. However, the effectiveness of prophylaxis on pulmonary embolism and mortality has not been demonstrated. Renal function needs to be evaluated when low molecular weight heparins, fondaparinux, rivaroxaban or dabigatran are prescribed. An age of over 75 years and low body weight (<50 kg) have to be taken into account. There is a risk of spinal or epidural hematoma in patients receiving anticoagulants. Caution should be taken especially when administering the newer agents. Patients undergoing surgery that involves a moderate or high overall risk should receive prophylaxis until full mobilization. Patients who have undergone a total hip replacement, surgery for hip fracture, or major abdominal surgery should receive prophylaxis for about 5 weeks longer. The relevance of distal vein thromboses is debated. Surrogate venographic end-points should be gradually replaced by a combination of ultrasound and clinical criteria. The new antithrombotic agents will probably modify prevention in the years to come but currently there are very few long-term data for these products for which - it should be reminded - no antagonists are available.

Topics: Adult; Aged; Anticoagulants; Combined Modality Therapy; Fibrinolytic Agents; Fondaparinux; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Middle Aged; Morpholines; Polysaccharides; Postoperative Complications; Preanesthetic Medication; Pulmonary Embolism; Risk Factors; Rivaroxaban; Stockings, Compression; Thiophenes; Thromboembolism; Thrombophlebitis; Vitamin K

Rivaroxaban is the first oral anticoagulant with a direct anti-Xa activity to be registered (approval). As for all first comers in a class, it should be assessed both for itself and for the class. The targeting of factor-Xa factor, key component in the coagulation cascade, has the theoretical benefit of being an effective antithrombotic and a potential risk for hemorrhage, both highly dose-dependent. Experience has shown us that the representativeness and predictiveness of in vitro tests and preclinical models are only partial and sometimes even misleading. This is why the responses can only come from clinical trials and rigorous research testing doses, which should be conducted specifically in all the indications foreseen, with no extrapolations. The oral anticoagulant drugs are developed in the prevention of arterial thromboembolic events caused by atrial fibrillation too, where the vitamin K antagonists (VKAs) are the current standard of care. The well-known problems of monitoring and adaptation doses with VKAs have led to developing new replacement classes without the need for control or biological adaptation. However, in certain conditions there is a need to monitor the patient. The advantage for the direct anti-Xa inhibitors such as rivaroxaban is that the prothrombin time, a routine test is sensitive and provides a prolonged response that is proportional to the plasma concentration within a wide range of concentrations. This test is potentially usable provided that the indispensable standardization is forthcoming.

Topics: Administration, Oral; Anticoagulants; Clinical Trials as Topic; Drug Administration Schedule; Drug Monitoring; Factor Xa Inhibitors; Fibrinolytic Agents; Hemorrhage; Heparin; Heparin, Low-Molecular-Weight; Humans; Molecular Structure; Morpholines; Postoperative Complications; Preanesthetic Medication; Prothrombin Time; Rivaroxaban; Thiophenes; Thrombin; Thromboembolism; Vitamin K; Warfarin

The risk of venous thromboembolism (VTE) is increased in association with malignancy, and has a potential to produce significant morbidity and mortality. Treatment of such patients with anticoagulants is associated with both benefit and a high rate of complications. In the early phase, the treatment is usually achieved with low molecular weight heparin (LMWH), which has a number of advantages over unfractionated heparin (UFH): once or twice daily administration, no necessary laboratory monitoring, lesser risk of bleeding and no drugs interactions. Nevertheless, the UFH is the anticoagulant of choice when a rapid anticoagulant effect or stop of anticoagulant effect is required, in the treatment of massive pulmonary embolism or severe renal insufficiency. Prolonged anticoagulation with LMWH (over 3 or 6 months) appears to be beneficial on survival for such patients. The subject of anticoagulation in patients with primary or secondary brain tumours is controversial. The long-term anticoagulation mainly use LMWH or vitamin K antagonist. The last ones are more difficult to use because of an unpredictable response with higher rate of recurrence and bleeding. The optimal duration of treatment is not known but the patients should be treated for at least 6 months, even at least 12 months after a second episode of venous thromboembolism. On the primary prevention in high-risk surgical oncology, the LMWH are at least as effective and safer as UFH when the optimal dose was administered. For the medical patients, the use of prophylactic anticoagulant treatment is less clear except the patients who are bedridden for prolonged periods of time. For the secondary prevention, the LMWH seems to be more effective over vitamin K antagonists. For these patients, the anticoagulant therapy is recommended indefinitely or until cancer is resolved.

Topics: Anticoagulants; Antineoplastic Agents, Hormonal; Heparin; Heparin, Low-Molecular-Weight; Humans; Neoplasms; Postoperative Complications; Tamoxifen; Thromboembolism; Venous Thrombosis; Vitamin K

Venous thromboembolism (VTE), which is manifested as deep vein thrombosis (DVT) and pulmonary embolism (PE), represents a significant cause of death, disability, and discomfort. They are frequent complications of various surgical procedures. The aging population and the survival of more severely injured patients may suggest an increasing risk of thromboembolism in the trauma patients. Expanded understanding of the population at risk challenges physicians to carefully examine risk factors for VTE to identify high-risk patients who can benefit from prophylaxis. An accurate knowledge of evidence-based risk factors is important in predicting and preventing postoperative DVT, and can be incorporated into a decision support system for appropriate thromboprophylaxis use. Standard use of DVT prophylaxis in a high-risk trauma population leads to a low incidence of DVT. The incidence of VTE is common in Asia. The evaluation includes laboratory tests, Doppler test and phlebography. Screening Doppler sonography should be performed for surveillance on all critically injured patients to identify DVT. D-Dimer is a useful marker to monitor prophylaxis in trauma surgery patients. The optimal time to start prophylaxis is between 2 hours before and 10 hours after surgery, but the risk of PE continues for several weeks. Thromboprophylaxis includes graduated compression stockings and anticoagulants for prophylaxis. Anticoagulants include Warfarin, which belongs to Vitamin K antagonists, unfractionated heparin, low molecular weight heparins, factor Xa indirect inhibitor Fondaparinux, and the oral IIa inhibitor Melagatran and ximelagatran. Recombinant human soluble thrombomodulin is a new and highly effective antithrombotic agent. Prophylactic placement of vena caval filters in selected trauma patients may decrease the incidence of PE. The indications for prophylactic inferior vena cava filter insertion include prolonged immobilization with multiple injuries, closed head injury, pelvic fracture, spine fracture, multiple long bone fracture, and attending discretion. Multiple-trauma patients are at increased risk for DVT but are also at increased risk of bleeding, and the use of heparin may be contraindicated. Serial compression devices (SCDs) are an alternative for DVT prophylaxis. Compression devices provide adequate DVT prophylaxis with a low failure rate and no device-related complications. Immobilization is one of important reasons of VTE. The ambulant patient is far less li

Topics: Anticoagulants; Factor Xa Inhibitors; Heparin; Heparin, Low-Molecular-Weight; Humans; Orthopedic Procedures; Postoperative Complications; Pulmonary Embolism; Recombinant Proteins; Risk Factors; Thrombomodulin; Vena Cava Filters; Venous Thrombosis; Vitamin K; Warfarin

Patients undergoing general surgery present an inherent risk of deep vein thrombosis (DVT). Evidence-based strategies for prevention and treatment of DVT should be continuously upgraded on the basis of good-quality recent trials.. Articles were identified using MEDLINE, EMBASE, and the Cochrane Library databases (January 1980 to July 2003). Randomized clinical trials and meta-analyses in which different prophylactic and treatment methods were compared for general surgery patients were selected.. In general surgery, low-molecular weight heparins (LMWHs) are relied upon more and more for prophylaxis and initial anticoagulant treatment of DVT, because of their multiple advantages in efficacy, safety, and convenience in handling. For cost-effective reasons, full-dose vitamin K antagonists are still preferred as the standard long-term anticoagulation method, while LMWHs represent the exception. Long-term use of low-intensity warfarin should be considered a new standard of care for the management of venous thrombosis. Compared to LMWH, the new anticoagulant molecules fondaparinux and ximelagatran seem to have similar efficacy in the treatment of venous thromboembolism, but they have a 2-fold increased efficacy in its prophylaxis. Clinical implementation of these new anticoagulant molecules depends on their cost-effectiveness; however, they have the potential to become the treatment of choice in the next decade. Thrombolysis has an unacceptable risk of hemorrhagic complications when used in the treatment of postoperative DVT. Furthermore, there are no data to prove that thrombolysis reduces the incidence of postthrombotic syndrome (PTS), despite early and complete recanalization achieved by thrombolysis. Surgical thrombectomy is only meant to decompress the venous hypertension consecutive to massive thrombosis (phlegmasia cerulea dolens) and thus to avoid venous gangrene. Other mechanical percutaneous thrombectomy devices are under evaluation. In selected cases, a combination treatment consisting of locoregional thrombolysis of the crurofemoral venous axis and mechanical thrombectomy of the pelvic venous axis achieves high rates of complete desobliteration.

Topics: Anticoagulants; Heparin, Low-Molecular-Weight; Humans; Postoperative Complications; Risk Assessment; Surgical Procedures, Operative; Thrombectomy; Thrombolytic Therapy; Venous Thrombosis; Vitamin K; Warfarin

Low-molecular-weight heparins (LMWHs) are used widely in the treatment and prevention of venous thromboembolism (VTE). The LMWHs dalteparin and enoxaparin reduce the rate of VTE by at least 50% if administered for 4-5 weeks following major orthopedic surgery, compared with in-hospital prophylaxis for 7-15 days. Meta-analyses have confirmed that the size of the reduction is similar for both clinical and asymptomatic VTE. Vitamin K antagonists (VKAs) have been shown to be associated with significantly higher bleeding rates compared with LMWH when used as prolonged prophylaxis against VTE following major orthopedic surgery. Patients with cancer are a recognized group at high risk of VTE, and those undergoing major surgery for their malignancy are at particular risk. Evidence from clinical trials is amassing to show that prolonged prophylaxis with LMWH (dalteparin, enoxaparin) in these patients can significantly reduce the rate of postoperative VTE. In cancer patients with acute VTE, the traditional approach is to initiate acute treatment with unfractionated heparin or LMWH followed by long-term treatment with VKA to prevent recurrence. However, clinical trial data have confirmed that the LMWH dalteparin, when administered for 6 months, is significantly more effective than VKA in preventing recurrence, cutting the rate of VTE by 52% without increasing the risk of bleeding. A new and intriguing area of interest is whether LMWH can enhance survival in patients with cancer. Preliminary data suggest that a biological effect of LMWH may act to prolong survival in patients with cancer.

Topics: Anticoagulants; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Neoplasms; Postoperative Complications; Premedication; Thromboembolism; Venous Thrombosis; Vitamin K

Topics: Azetidines; Benzylamines; Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Humans; Orthopedic Procedures; Postoperative Complications; Therapeutic Equivalency; Thromboembolism; Venous Thrombosis; Vitamin K

The benefit-to-risk ratio of vitamin K antagonists (VKA), relative to active comparators, especially low-molecular-weight heparins (LMWH), for preventing venous thromboembolism in patients undergoing major orthopedic surgery is debated.. We performed a meta-analysis of all randomized trials in orthopedic surgery comparing adjusted doses of VKA to control treatments.. An exhaustive literature search, both manual and computer-assisted, was performed. Studies were selected on the basis of randomization procedure (VKA vs. a control group). At least one of the following outcome measures was to be evaluated: deep vein thrombosis (DVT), pulmonary embolism (PE), death, major hemorrhage or wound hematoma. Four reviewers assessed each article to determine eligibility for inclusion and outcome measures.. VKAs were more effective than placebo or no treatment in reducing DVT [567 patients, relative risk (RR) = 0.56, 95% confidence interval (CI) 0.37, 0.84, P < 0.01] and clinical PE (651 patients, RR = 0.23, 95% CI 0.09, 0.59, P < 0.01). These results were obtained at the cost of a higher rate of wound hematoma (162 patients, RR = 2.91, 95% CI 1.09, 7.75, P = 0.03). VKAs were also more effective than intermittent pneumatic compression (534 patients, RR = 0.46, 95% CI 0.25, 0.82, P = 0.009) in preventing proximal DVT. In contrast, VKAs were less effective than LMWH in preventing total DVT and proximal DVT (9822 patients, RR = 1.51, 95% CI 1.27, 1.79, P < 0.001; and 6131 patients, RR = 1.51, 95% CI 1.04, 2.17, P = 0.028, respectively). The differences between VKA and LMWH in major hemorrhage and wound hematoma were not significant.. In patients undergoing major orthopedic surgery, VKAs are less effective than LMWH, without any significant difference in the bleeding risk.

Topics: Fibrinolytic Agents; Hemorrhage; Humans; Orthopedic Procedures; Postoperative Complications; Randomized Controlled Trials as Topic; Survival Rate; Therapeutic Equivalency; Thromboembolism; Venous Thrombosis; Vitamin K

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following. We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). For moderate-risk general surgery patients, we recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [< or = 3,400 U once daily] (both Grade 1A). For higher risk general surgery patients, we recommend thromboprophylaxis with LDUH (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. For high-risk general surgery patients with multiple risk factors, we recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). We recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures, and we recommend prophylaxis with LDUH two times or three times daily (Grade 1A). For patients undergoing elective total hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty, or HFS receive thromboprophylaxis for at least 10 days (Grade 1A). We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, we recommend prophylaxis with LDUH (Grade 1A) or LMWH

Topics: Anticoagulants; Aspirin; Dose-Response Relationship, Drug; Drug Administration Schedule; Drug Therapy, Combination; Evidence-Based Medicine; Fondaparinux; Heparin; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Polysaccharides; Postoperative Complications; Pulmonary Embolism; Randomized Controlled Trials as Topic; Risk Assessment; Venous Thrombosis; Vitamin K

This chapter about antithrombotic therapy in native and prosthetic valvular heart disease is part of the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following: For patients with rheumatic mitral valve disease and atrial fibrillation (AF), or a history of previous systemic embolism, we recommend long-term oral anticoagulant (OAC) therapy (target international normalized ratio [INR], 2.5; range, 2.0 to 3.0) [Grade 1C+]. For patients with rheumatic mitral valve disease with AF or a history of systemic embolism who suffer systemic embolism while receiving OACs at a therapeutic INR, we recommend adding aspirin, 75 to 100 mg/d (Grade 1C). For those patients unable to take aspirin, we recommend adding dipyridamole, 400 mg/d, or clopidogrel (Grade 1C). In people with mitral valve prolapse (MVP) without history of systemic embolism, unexplained transient ischemic attacks (TIAs), or AF, we recommended against any antithrombotic therapy (Grade 1C). In patients with MVP and documented but unexplained TIAs, we recommend long-term aspirin therapy, 50 to 162 mg/d (Grade 1A). For all patients with mechanical prosthetic heart valves, we recommend vitamin K antagonists (Grade 1C+). For patients with a St. Jude Medical (St. Paul, MN) bileaflet valve in the aortic position, we recommend a target INR of 2.5 (range, 2.0 to 3.0) [Grade 1A]. For patients with tilting disk valves and bileaflet mechanical valves in the mitral position, we recommend a target INR of 3.0 (range, 2.5 to 3.5) [Grade 1C+]. For patients with caged ball or caged disk valves, we suggest a target INR of 3.0 (range, 2.5 to 3.5) in combination with aspirin, 75 to 100 mg/d (Grade 2A). For patients with bioprosthetic valves, we recommend vitamin K antagonists with a target INR of 2.5 (range, 2.0 to 3.0) for the first 3 months after valve insertion in the mitral position (Grade 1C+) and in the aortic position (Grade 2C). For patients with bioprosthetic valves who are in sinus rhythm and do not have AF, we recommend long-term (> 3 months) therapy with aspirin, 75 to 100 mg/d (Grade 1C+).

Topics: Aspirin; Bioprosthesis; Evidence-Based Medicine; Fibrinolytic Agents; Heart Valve Diseases; Heart Valve Prosthesis; Humans; International Normalized Ratio; Postoperative Complications; Prosthesis Design; Randomized Controlled Trials as Topic; Risk Assessment; Secondary Prevention; Thromboembolism; Vitamin K

To elucidate predisposing factors for enlargement of intracerebral hematoma (ICH) during warfarin therapy, we reviewed 47 patients on warfarin who developed acute ICH and determined relationships among ICH enlargement, INR reversal and clinical data. Among 36 patients treated to counteract the effects of warfarin within 24 h of onset, ICH increased in 10 patients (enlarged group), but remained unchanged in the remaining 26 (unchanged group), while ICH remained unchanged in another 11 patients in whom the effect of warfarin was reversed after 24 h. The international normalized ratio (INR) was counteracted immediately in 11 patients treated with prothrombin complex concentrate (PCC) but gradually in the other 36 treated by reducing the dose of warfarin, or by administering vitamin K or fresh frozen plasma. Multivariate analysis with a logistic regression model showed an INR value <2.0 at admission or for 24 h after immediate INR correction with PCC prevented ICH enlargement (OR 0.069, 95%CI 0.006-0.789, p = 0.031). An INR value of >2.0 within 24 h of ICH seems an important predisposing factor for ICH enlargement.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Cerebral Hemorrhage; Comorbidity; Diabetes Mellitus; Disease Progression; Female; Humans; Hypercholesterolemia; Hypertension; International Normalized Ratio; Liver Diseases; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Risk Factors; Tomography, X-Ray Computed; Vitamin K; Warfarin

Chronic peripheral arterial disease (PAD) is frequently treated by implantation of either an infrainguinal autologous venous or artificial graft. One-year occlusion rates for infrainguinal bypasses vary between 15 and 75%, depending on the site of distal anastomosis, length, quality, and material of the graft, but also on other factors such as proximal inflow and distal outflow conditions. To prevent graft occlusion, patients are usually treated with either an antiplatelet or antithrombotic drug, or a combination of both. Little is known about which drug is optimal to prevent infrainguinal graft occlusion.. To evaluate whether antithrombotic treatment in patients with chronic PAD undergoing infrainguinal bypass surgery improves graft patency, limb salvage and survival by performing a meta-analysis of performed RCTs.. The search strategy was that adopted by the Cochrane Review Group on Peripheral Vascular Diseases. Additional data bases were reviewed (Reference lists of papers resulting from this search, MEDLINE from 1966-onwards and EMBASE from 1980-onwards using the terms 'anticoagulant' and 'arterial surgery'.. The methodological quality of each trial was assessed independently by at least two reviewers using the checklist provided by the Peripheral Vascular Diseases Collaborative Review Group, with emphasis on concealment of randomisation. Each trial was given an allocation score of A (clearly concealed), B (unclear if concealed), or C (clearly not concealed) and a summary score of A (low risk of bias), B (moderate risk), or C (high risk). Trials scoring A were included and those scoring C were excluded. For a trial scoring B, an attempt was made to obtain more information by contacting the author.. For each trial, the number of patients originally allocated to each treatment group was extracted from the data and an 'intention to treat' analysis performed. Data collection on each trial included inclusion and exclusion criteria, patient details, type of graft, type and dose of antithrombotic therapy used, outcome, and side effects. The treatment and control groups were compared for important prognostic factors and differences described. If any of the above data was not available, further information was sought from the author. However, the heterogeneity between trials could not be tested due to inaccessible data. Data were synthesized by comparing group results.. The analysis including four trials which evaluated vitamin K antagonists (VKA) versus no VKA indicate, that oral anticoagulation tendentially favours venous but not artificial graft patency as well as limb salvage and survival. Two other studies comparing VKA with aspirin or aspirin/dipyridamole supported evidence for a positive effect of VKA on the patency of venous but not artificial grafts. Subgroup analysis for artificial grafts as performed in one trial showed a favourable effect of antiplatelet agents on synthetic bypasses. In two trials with a relatively small number of patients low molecular weight heparin treatment was associated with a lower incidence of early postoperative graft thrombosis compared to treatment with unfractionated heparin. In one trial infusion of antithrombin concentrate was reported to have a negative effect on intraoperative graft thrombosis necessitating the study to be stopped before termination. Perioperative administration of ancrod was compared to unfractionated heparin showing no benefit of one drug compared to the other.. Patients operated for an infrainguinal venous graft might benefit from treatment with VKA, whereas patients receiving an artificial graft might profit more from platelet inhibitors (aspirin). However, the evidence is not conclusive. Randomised controlled trials with larger patient numbers comparing antithrombotic therapies with either placebo or antiplatelet therapies are called for in the future.

Topics: Arteriosclerosis; Fibrinolytic Agents; Graft Occlusion, Vascular; Humans; Intermittent Claudication; Ischemia; Leg; Peripheral Vascular Diseases; Postoperative Complications; Randomized Controlled Trials as Topic; Thrombosis; Vitamin K

Anticoagulants are widely used for the prevention and treatment of venous and arterial thrombosis. Current treatment strategies often employ a combination of parenteral and oral agents because the only available orally active anticoagulants, vitamin K antagonists, have a delayed onset of action. Furthermore, vitamin K antagonists have a narrow therapeutic window that necessitates careful anticoagulation monitoring, and dosing is problematic because of multiple food and drug interactions. These limitations highlight the need for oral anticoagulants that produce a more predictable anticoagulant response than vitamin K antagonists, thereby obviating the need for laboratory monitoring. Ximelagatran has the potential to meet this need. A prodrug of melagatran, an agent that targets thrombin, ximelagatran exhibits many of the characteristics of an ideal anticoagulant. This article (1). reviews the limitations of vitamin K antagonists, (2). lists the characteristics of an ideal anticoagulant, (3). rationalizes thrombin as a target for new anticoagulants, (4). reviews the preclinical and clinical data with ximelagatran, and (5). provides clinical perspective as to the future of ximelagatran and other orally active anticoagulants currently under development.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Azetidines; Benzylamines; Blood Coagulation; Drug Monitoring; Glycine; Humans; International Normalized Ratio; Postoperative Complications; Prodrugs; Stroke; Thrombin; Thrombosis; Venous Thrombosis; Vitamin K

Topics: Anticoagulants; Blood Coagulation; Drug Interactions; Female; Fibrinolytic Agents; Heparin; Heparin, Low-Molecular-Weight; Humans; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Thromboembolism; Time Factors; Venous Thrombosis; Vitamin K

Thrombotic occlusion after vascular reconstructive surgery is a frequent complication, specially when low-flow arteries and arterial prostheses are involved. Heparin therapy is usually administered in acute arterial insufficiency, and also during the perioperative period, in order to limit thrombus formation or propagation at the surgical or the cross-clamp application sites. The overall benefit of antiplatelet agents, specially aspirin, during the pre, peri and postoperative periods has been clearly demonstrated for arterial prostheses, and is probably useful in venous bypasses. Aspirin therapy also prevents thrombotic complication in other vascular beds, and reduces long-term cardiovascular morbidity and mortality. Oral anticoagulation by vitamin K antagonists, alone or combined with aspirin is perhaps an appropriate choice in selected patients with high risk of graft thrombosis, but cannot be recommended for routine treatments because of an increased risk of hemorrhage.

Topics: 4-Hydroxycoumarins; Anticoagulants; Arteries; Aspirin; Drug Therapy, Combination; Fibrinolytic Agents; Hemorrhage; Heparin; Humans; Indenes; Platelet Aggregation Inhibitors; Postoperative Complications; Thrombosis; Vascular Surgical Procedures; Vitamin K

Patients under oral anticoagulation with coumarin derivatives have a variable perioperative thromboembolic risk which necessitates continuation of their thromboembolic prophylaxis during elective and emergency surgery. Because of their better handling unfractionated heparin and low-molecular-weight heparins are used most often for this purpose. The overlapping effect of coumarin and heparin therapy requires a close daily monitoring of the clotting inhibition (partial thromboplastin time, thromboplastin time, thrombin time). In elective surgery coumarin therapy is interrupted 2-3 days preoperatively; in emergency cases vitamin K or fresh frozen plasma have to be substituted. Patients under heparin therapy or prophylaxis are easier to handle, because the effect of heparin disappears in a few hours after stopping the treatment. In the immediate postoperative phase the heparin application is interrupted for 6 h because of increased bleeding risk. It is important to take into account additional risk factors like the underlying disease, disturbances of platelet function, liver diseases and renal insufficiency.

Topics: Anticoagulants; Blood Coagulation Tests; Drug Administration Schedule; Elective Surgical Procedures; Emergencies; Humans; Intraoperative Complications; Plasma; Postoperative Complications; Postoperative Hemorrhage; Risk; Vitamin K

Topics: 4-Hydroxycoumarins; Anticoagulants; Aspirin; Dextrans; Heparin; Hip Prosthesis; Humans; Indenes; Knee Joint; Knee Prosthesis; Postoperative Complications; Thrombophlebitis; Vitamin K

Topics: 4-Hydroxycoumarins; Anesthesia, Spinal; Anticoagulants; Dextrans; Digestive System Diseases; Female; Genital Diseases, Female; Hemodilution; Heparin; Humans; Indenes; Leg Injuries; Male; Postoperative Complications; Pulmonary Embolism; Thrombophlebitis; Vitamin K

Topics: Bandages; Dextrans; Dihydroergotamine; Heparin; Humans; Incidence; Postoperative Complications; Risk Factors; Thromboembolism; Vitamin K

Topics: Adult; Aged; Anesthesia; Bandages; Dextrans; Female; Fibrinogen; Genital Diseases, Female; Heparin; Humans; Middle Aged; Postoperative Complications; Predictive Value of Tests; Risk Factors; Thromboembolism; Vitamin K

Topics: Anesthesia; Aspirin; Bandages; Dextrans; Female; France; Heparin, Low-Molecular-Weight; Humans; Male; Postoperative Complications; Pulmonary Embolism; Thrombosis; Vitamin K

Oral anticoagulants are used extensively, although their risks are not always fully recognized. The prophylaxis of venous thrombosis after hip surgery, the prevention of deep venous thrombosis and pulmonary emboli after an acute episode of these, the prevention of arterial emboli from the heart in patients at risk, and the prophylaxis of thrombosis in patients with congenital deficiency of antithrombin III, protein C, or protein S are some of the indications for oral anticoagulant use. Warfarin sodium is contraindicated in pregnancy, however. The recommended prothrombin time is 1 1/2 to two times control, lower than previously. The major risk of oral anticoagulant therapy, bleeding, is treated with vitamin K or plasma, depending on its severity. Warfarin necrosis and the "purple-toe" syndrome are seen more frequently than realized.

Topics: Absorption; Administration, Oral; Biological Availability; Drug Interactions; Hemorrhage; Hip Fractures; Humans; Myocardial Infarction; Necrosis; Postoperative Complications; Protein Binding; Prothrombin Time; Pulmonary Embolism; Thrombophlebitis; Thrombosis; Vitamin K; Warfarin

Topics: Anticoagulants; Dextrans; Dipyridamole; Femoral Neck Fractures; Heparin; Hip Joint; Humans; Hydroxychloroquine; Joint Prosthesis; Postoperative Complications; Risk; Thromboembolism; Thrombophlebitis; Vitamin K

Topics: Acute Disease; Anticoagulants; Atrial Fibrillation; Cell Transformation, Neoplastic; Disseminated Intravascular Coagulation; Dose-Response Relationship, Drug; Embolization, Therapeutic; Female; Hemorrhage; Heparin; Humans; Mitral Valve; Postoperative Complications; Pregnancy; Pulmonary Embolism; Thrombocytopenia; Thromboembolism; Thrombophlebitis; Vitamin K; Warfarin

Topics: Blood Coagulation; Blood Coagulation Disorders; Blood Coagulation Factors; Blood Transfusion; Hemorrhage; Hemostasis; Heparin; Humans; Liver Diseases; Medical History Taking; Postoperative Complications; Preoperative Care; Surgical Procedures, Operative; Thrombocytopenia; Uremia; Vitamin K

The role of direct oral anticoagulants as compared with vitamin K antagonists for atrial fibrillation after successful transcatheter aortic-valve replacement (TAVR) has not been well studied.. We conducted a multicenter, prospective, randomized, open-label, adjudicator-masked trial comparing edoxaban with vitamin K antagonists in patients with prevalent or incident atrial fibrillation as the indication for oral anticoagulation after successful TAVR. The primary efficacy outcome was a composite of adverse events consisting of death from any cause, myocardial infarction, ischemic stroke, systemic thromboembolism, valve thrombosis, or major bleeding. The primary safety outcome was major bleeding. On the basis of a hierarchical testing plan, the primary efficacy and safety outcomes were tested sequentially for noninferiority, with noninferiority of edoxaban established if the upper boundary of the 95% confidence interval for the hazard ratio did not exceed 1.38. Superiority testing of edoxaban for efficacy would follow if noninferiority and superiority were established for major bleeding.. A total of 1426 patients were enrolled (713 in each group). The mean age of the patients was 82.1 years, and 47.5% of the patients were women. Almost all the patients had atrial fibrillation before TAVR. The rate of the composite primary efficacy outcome was 17.3 per 100 person-years in the edoxaban group and 16.5 per 100 person-years in the vitamin K antagonist group (hazard ratio, 1.05; 95% confidence interval [CI], 0.85 to 1.31; P = 0.01 for noninferiority). Rates of major bleeding were 9.7 per 100 person-years and 7.0 per 100 person-years, respectively (hazard ratio, 1.40; 95% CI, 1.03 to 1.91; P = 0.93 for noninferiority); the difference between groups was mainly due to more gastrointestinal bleeding with edoxaban. Rates of death from any cause or stroke were 10.0 per 100 person-years in the edoxaban group and 11.7 per 100 person-years in the vitamin K antagonist group (hazard ratio, 0.85; 95% CI, 0.66 to 1.11).. In patients with mainly prevalent atrial fibrillation who underwent successful TAVR, edoxaban was noninferior to vitamin K antagonists as determined by a hazard ratio margin of 38% for a composite primary outcome of adverse clinical events. The incidence of major bleeding was higher with edoxaban than with vitamin K antagonists. (Funded by Daiichi Sankyo; ENVISAGE-TAVI AF ClinicalTrials.gov number, NCT02943785.).

Topics: 4-Hydroxycoumarins; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Factor Xa Inhibitors; Female; Gastrointestinal Hemorrhage; Humans; Intention to Treat Analysis; Kaplan-Meier Estimate; Male; Mortality; Phenindione; Postoperative Complications; Pyridines; Thiazoles; Thromboembolism; Transcatheter Aortic Valve Replacement; Vitamin K

Kidney transplant recipients (KTRs) experience substantial survival benefit compared with dialysis patients. However, their mortality and graft failure risk remain high. KTRs are often low in micronutrient status, including vitamins D and K. We investigated the association of both vitamins D and K status, and vitamin D treatment with all-cause mortality and death-censored graft failure.. We studied 461 KTRs from a single-centre study at median 6.1 years after transplantation. At baseline, vitamins D and K concentrations were measured by 25-hydroxyvitamin D [25(OH)D] and dephosphorylated uncarboxylated matrix gla protein (dp-ucMGP) and patients were categorized into: 25(OH)D <50/≥50 nmol/L and median dp-ucMGP <1057/≥1057 pmol/L.. Mean age was 52 ± 12 years, and 122 KTRs (26%) had low vitamins D and K status. During median 9.8 years follow-up, 128 patients (28%) died and 48 (10%) developed death-censored graft failure. Low vitamins D and K status was associated with 2.33 (1.26-4.30) [hazard ratio (95% confidence interval)] increased mortality risk and 3.25 (1.17-9.08) increased graft failure risk compared with KTR with 25(OH)D ≥50 nmol/L and dp-ucMGP <1057 pmol/L. Dp-ucMGP was strongly associated with mortality (per 500 pmol/L increase): 1.41 (1.08-1.41) for vitamin D treatment versus no treatment 1.07 (0.97-1.18), and graft failure 1.71 (1.17-2.49) for vitamin D treatment versus 1.19 (1.05-1.36) no treatment, P-interaction <0.07 for vitamin D treatment (n = 44).. Combined vitamins D and K deficiency are highly prevalent and are associated with increased mortality and graft failure risk compared with high vitamins D and K status. Low vitamin K status was strongly associated with an increased risk of premature mortality and graft failure for patients treated with vitamin D versus no vitamin D treatment.

Topics: Female; Graft Rejection; Graft Survival; Humans; Kidney Diseases; Kidney Transplantation; Male; Middle Aged; Postoperative Complications; Prognosis; Prospective Studies; Survival Rate; Vitamin D; Vitamin K; Vitamin K Deficiency

Deep vein thrombosis (DVT) and pulmonary embolisms (PEs) are common complications after surgical procedures. The influence of prescribed blood products on the occurrence of DVT and PE was evaluated in postsurgical patients in this retrospective case-control study. The records of 286 surgical patients were analyzed: DVT (n = 52), PE (n = 92), and a control group (n = 142). The amounts of prescribed blood, blood products, and vitamin K were reviewed, together with appropriate prescribing of low-molecular-weight heparins. The influence of prescribed blood products on the occurrence of DVT or PE was analyzed using multinomial logistic regression. We demonstrated a significant difference between the test and control groups ( P < .05) in relation to receiving packed red blood cells. Treatment with red blood cells was associated with an increased risk of PE but not DVT. Patients who developed PE after surgery were hospitalized for longer (median 10 days) than patients with DVT (median 6 days). There was no difference between the test and control groups concerning treatment with fresh frozen plasma. Inadequate thromboprophylaxis significantly increased the likelihood of DVT. There is a connection between receiving packed red blood cells and occurrence of postoperative PE in surgical patients. Thus, patients receiving red blood cells should be monitored more closely after surgery, as they are more likely to develop PE postoperatively.

Topics: Aged; Aged, 80 and over; Erythrocyte Transfusion; Female; Heparin, Low-Molecular-Weight; Humans; Incidence; Male; Middle Aged; Plasma; Postoperative Complications; Pulmonary Embolism; Retrospective Studies; Venous Thrombosis; 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

Body weight-adjusted subcutaneous low-molecular-weight heparin (LMWH) has been proven to be at least as effective and safe as dose-adjusted intravenous unfractionated heparin (UFH) for the treatment of patients with venous thromboembolism. However, body weight-adjusted dosage of low-molecular-weight heparin may be cumbersome and could lead possibly to incorrect dosing. Therefore a fixed LMWH dose, independent of body-weight, might rationalize initial treatment for venous thromboembolism.. Patients with proven proximal deep-vein thrombosis were randomly assigned to fixed dose subcutaneous LMWH Certoparin (8,000 anti-factor Xa U b.i.d.; 265 patients) or to adjusted dose i.v. UFH (273 patients) for 12 days. Vitamin K antagonists were started between day 3 and 7 and continued for up to 6 months. The primary outcome measure was a 30 percent or greater improvement in the Marder Score, as revealed by repeated venography on day 12 (end of the initial treatment). The secondary composite outcome measure included death, recurrent venous thromboembolism and major bleeding and was assessed at day 12 and after 6 months by a blinded adjunction committee.. The Marder score improved by 30% or more in 30.3% and 25.0% of patients assigned to LMWH (198 paired venograms) and UFH (192 paired venograms), respectively (2p = 0.26). At the end of the initial treatment, the composite outcome was observed in 4 of the 265 patients (1.5%) randomized to LMWH, as compared with 14 of the 273 patients (5.1%) randomized to UFH (2p = 0.03). At 6 months these figures were 6.8% and 12.8%, respectively (risk reduction 0.53, confidence interval 0.31-0.90, 2p = 0.02).. Fixed dose subcutaneous LMWH certoparin is at least as efficacious as UFH in resolving proximal vein thrombosis.

Topics: Acute Disease; Adult; Aged; Anticoagulants; Body Weight; Cohort Studies; Female; Hemorrhage; Heparin; Heparin, Low-Molecular-Weight; Humans; Injections, Intravenous; Injections, Subcutaneous; Male; Middle Aged; Phlebography; Popliteal Vein; Postoperative Complications; Recurrence; Treatment Outcome; Venous Thrombosis; Vitamin K

Topics: Aortic Valve; Dipyridamole; Drug Therapy, Combination; Heart Valve Prosthesis; Humans; Mitral Valve; Postoperative Complications; Prospective Studies; Thromboembolism; Vitamin K

The aim of this clinical observational study was to assess the efficacy of L-PRF as a hemostatic agent in patients under treatment with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs).. Patients under oral anticoagulant therapy (VKA or DOACs) who needed a single simple tooth extraction were enrolled. L-PRF plug was positioned inside the alveolus and secured with non-absorbable sutures. Surgical time, pain-VAS, paracetamol intake, intra-operative, post-operative biological complications, and bleeding events have been registered.. A total of 112 patients (59 patients for DOAC and 53 for VKA group) were enrolled. Post-operative bleeding was recorded in nine patients (17%) for VKA group and nine patients (15.3%) for DOACs group. None of the patients needed a medical support for managing of bleeding. Seven days after surgery, no cases of post-extractive complications occurred.. The use of L-PRF resulted in limited mild late post-operative bleedings without the need of medical intervention.. The use of L-PRF can be adopted for an uneventful post-operative curse in anticoagulated patients without chasing their therapy for single tooth extraction.

Topics: Administration, Oral; Anticoagulants; Cohort Studies; Hemostatics; Humans; Platelet-Rich Fibrin; Postoperative Complications; Postoperative Hemorrhage; Tooth Extraction; Vitamin K

Recommendations for perioperative management of direct oral anticoagulant (DOAC) treatment in cardiac surgery are lacking. To establish a standardized approach for these patients, we compared hemorrhagic complications and clinical outcomes in patients on DOAC medication, patients on vitamin K antagonists (VKA), and patients without preoperative anticoagulation.. All 3 groups underwent major cardiac surgery and were retrospectively analyzed: patients on DOAC were advised to take their last DOAC dose 4 days before hospital admission, and DOAC plasma levels were measured the day before surgery. In patients with plasma levels of >30 ng/mL, surgery was postponed until plasma level was below this threshold level. Postoperative chest tube drainage, bleeding complications, use of blood products, and thromboembolic events were collected for all groups.. A total of 5439 patients no anticoagulation, 239 patients on VKA, and 487 patients on DOAC medication were included between April 2014 and July 2017. Adjusted postoperative chest tube drainage did not differ between the DOAC and VKA groups for the strategy applied in this study (380 mL/12 hours vs 360 mL/12 hours). Moreover, secondary endpoint measures, such as rethoracotomy (30 [6.16%] vs 15 [6.28%]), 30-day-mortality 12 [2.46%] vs 7 [2.93%]), blood-product use, and stroke, were not significantly different through implementation of our standardized study management (P > .05).. Our standardized management for perioperative discontinuation of DOAC therapy may provide a safe approach to minimize hemorrhagic complications in cardiac surgery in patients on DOACs.

Topics: Aged; Anticoagulants; Blood Transfusion; Cardiac Surgical Procedures; Factor Xa Inhibitors; Female; Germany; Hemorrhage; Humans; Male; Outcome and Process Assessment, Health Care; Perioperative Care; Postoperative Complications; Reoperation; Risk Adjustment; Thromboembolism; Vitamin K

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

Managing severe valvular heart disease with mechanical valve replacement necessitates lifelong anticoagulation with a vitamin K antagonist. Optimal anticoagulation intensity for patients with mechanical valves remains uncertain; current recommendations are inconsistent across guideline bodies and largely based on expert opinion. In this review, we outline the history of anticoagulation therapy in patients with mechanical heart valves and critically evaluate current antithrombotic guidelines for these patients. We conclude that randomized trials evaluating optimal anticoagulation intensity in patients with mechanical valves are needed, and that future guidelines must better justify antithrombotic treatment recommendations.

Topics: Anticoagulants; Atrial Fibrillation; Drug Monitoring; Health Services Needs and Demand; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; History, 20th Century; History, 21st Century; Humans; Multicenter Studies as Topic; Postoperative Complications; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Thrombophilia; Vitamin K

To evaluate the safety of holmium laser enucleation of the prostate (HoLEP) in patients on oral anticoagulation (OA) with respect to intra- and postoperative bleeding complications.. Between January 2013 and October 2016, 2178 patients were included in this study, of whom 94 received direct oral anticoagulants (DOACs) and 151 received vitamin K antagonists (VKAs) before HoLEP. All patients either ceased OA (DOACs) or were bridged subtherapeutically (VKAs, international normalized ratio <2) during surgery. These patients were compared to a sample size of 1933 nonanticoagulated patients.. A significant longer postoperative stay was noted for the patients on DOACs (5.2 [4-6] days) and VKAs (5.3 [4-5] days) compared to the control group (4.5 [4-4] days). The mean drop in hemoglobin was significantly higher in the VKA group compared to the DOAC and control group. There was a significantly higher rate of postoperative bladder tamponades/secondary coagulation in patients on OA with 6 (7.9%)/3 (3.9%) patients in the DOAC group, 10 (7.4%)/6 (4.4%) patients in the VKA group compared to 37 (2.2%)/21 (2.1%) patients in the control group, respectively (p < 0.001). Eight patients required blood transfusions with a distribution of 1 (1.3%), 3 (2.2%), and 4 (0.2%) patients in the DOAC, VKA, and control group, respectively (p < 0.001).. Our findings indicate that bridged patients who's DOACs and VKAs were ceased before HoLEP are at higher risk of intra- and postoperative bleeding complications. Nonetheless, HoLEP appears to be a safe and effective procedure in those patients.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Blood Transfusion; Holmium; Humans; Laser Therapy; Lasers, Solid-State; Male; Middle Aged; Patient Safety; Perioperative Period; Postoperative Complications; Postoperative Hemorrhage; Prostatectomy; Prostatic Hyperplasia; Retrospective Studies; Transurethral Resection of Prostate; Vitamin K

Complete graft thrombosis is the leading cause of early graft loss following pancreas transplantation. Partial thrombosis is usually subclinical and discovered on routine imaging. Treatment options may vary in such cases. We describe the incidence and relevance of partial graft thrombosis in a large transplant center. All consecutive pancreas transplantation at our center (2004-2015) were included in this study. Radiological follow-up, type and quantity of thrombosis prophylaxis, complications and, graft and patient survival were collected. Partial thrombosis and follow-up were also studied. All 230 pancreas transplantations were included in the analysis. Computed tomography was performed in most cases (89.1%). Early graft failure occurred in 23 patients (13/23 due to graft thrombosis, 3/23 bleeding, 1/23 anastomotic leakage, 6/23 secondary to antibody mediated rejection). There was evidence of partial thrombosis in 59 cases (26%), of which the majority was treated with heparin and a vitamin K antagonist with graft preservation in 57/59 patients (97%). Thrombosis is the leading cause of early graft loss following pancreas transplantation. Computed tomography allows for early detection of partial thrombosis, which is usually subclinical. Partial graft thrombosis occurs in about 25% of all cases. In this series, treatment with anticoagulant therapy (heparin and vitamin K antagonist) resulted in graft preservation in almost all cases.

Topics: Adult; Female; Graft Rejection; Heparin, Low-Molecular-Weight; Humans; Male; Middle Aged; Pancreas Transplantation; Postoperative Complications; Retrospective Studies; Thrombosis; Tomography, X-Ray Computed; 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

Topics: Administration, Oral; Ambulatory Surgical Procedures; Anticoagulants; Clinical Protocols; Contraindications, Drug; Drug Substitution; Elective Surgical Procedures; Heparin, Low-Molecular-Weight; Humans; Interdisciplinary Communication; Perioperative Care; Personnel, Hospital; Postoperative Complications; Postoperative Hemorrhage; Thromboembolism; Videoconferencing; Vitamin K

Clinicians struggle daily with the optimal regimen for patients with an indication for antiplatelet therapy after stenting and in patients needing oral anticoagulation treatment for atrial fibrillation (AF). This is not only difficult in patients with acute coronary syndrome (ACS) but also in the large number of patients with AF undergoing elective percutaneous coronary intervention (PCI). The challenge is to strike a balance between the increasing risk of bleeding events and ischemic or thrombotic events. Until recently, guidelines were based on expert consensus and a few small, many of them retrospective, trials. A so-called triple therapy with a vitamin K antagonist (VKA) and dual antiplatelet therapy (DAPT) with aspirin and clopidogrel was recommended for patients with AF undergoing PCI in stable coronary artery disease or for those with ACS. However, severe bleeding complications remain a major issue during triple therapy, particularly in the growing aging population. In the past year, randomized controlled trials (RCT) with direct-acting oral anticoagulants (DOACs) have modified the standard use of care, now favoring dual therapy with DOACs. This review elucidates the current influential RCTs on the new antiplatelet and anticoagulation strategies for patients with AF undergoing PCI or with ACS, and discusses whether triple therapy is still required.

Topics: Acute Coronary Syndrome; Administration, Oral; Anticoagulants; Aspirin; Atrial Fibrillation; Clopidogrel; Drug Therapy, Combination; Guideline Adherence; Hemorrhage; Humans; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Postoperative Complications; Randomized Controlled Trials as Topic; Risk Factors; Stents; Stroke; Thrombosis; Vitamin K

The safety and efficacy of a minimally interrupted novel oral anticoagulant (NOAC) strategy at the time of atrial fibrillation (AF) ablation is uncertain. The purpose of this study was to compare rates of bleeding and thromboembolic events between minimally interrupted NOAC and uninterrupted vitamin K antagonist (VKA) in patients undergoing AF ablation.. This was a retrospective single-center cohort study of consecutive patients who underwent AF catheter ablation between January 2013 and April 2017. Endpoints included major bleeding, clinically relevant non-major bleeding and systemic thromboembolic event from the time of ablation through 30 days. Bleeding events were defined by the Bleeding Academic Research Consortium (BARC) and International Society on Thrombosis and Haemostasis (ISTH).. A total of 637 patients were included in the analysis, 520 patients used uninterrupted VKA and 117 patients minimally interrupted NOAC (dabigatran: n = 68; apixaban: n = 30; rivaroxaban, n = 14; edoxaban, n = 5). The rate of clinically relevant non-major bleeding was lower in the NOAC group in comparison to the VKA group (BARC type 2: 2.6% versus 8.3%, P = 0.03; ISTH: 0% versus 3.8%, P = 0.03). Rates of major bleeding were similar between groups (BARC type 3 to 5: 3.4% versus 4.2%, P = NS; ISTH: 6.0% versus 8.7%, P = NS; for NOAC and VKA groups, respectively). Rates of systemic embolism were 0% with minimally interrupted NOAC, and 0.6% with uninterrupted VKA (P = NS).. In patients undergoing AF ablation, anticoagulation with minimally interrupted NOAC was associated with fewer clinically relevant non-major bleeding events in comparison with uninterrupted VKA without compromising thromboembolic safety.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Cohort Studies; Factor Xa Inhibitors; Female; Hemorrhage; Humans; Male; Middle Aged; Netherlands; Outcome and Process Assessment, Health Care; Postoperative Complications; Retrospective Studies; Thromboembolism; Vitamin K

Data evaluating the impact of the periprocedural administration of novel oral anticoagulants (NOACs) on complications in the setting of pulmonary vein (PV) isolation using cryoballoon (CB) is limited. In the present study, our aim was to analyze procedural characteristics and incidence of complications in those patients who underwent CB ablation for atrial fibrillation and the impact of NOACs on adverse events compared with vitamin K antagonists (VKAs). Consecutive patients with drug resistant atrial fibrillation who underwent PV isolation by CB as index procedure were retrospectively included in our analysis. In group I, 290 of 454 patients (63.9%) received VKAs (warfarin: n = 222 and acenocoumarol: n = 68), and in group II, 164 of 454 patients (36.1%) were treated with NOACs (rivaroxaban: n = 71; dabigatran: n = 60; and apixaban: n = 33). Age was significantly higher in the group II (62.8 ± 9.7 vs 58.6 ± 11.3; p <0.001). During the study period, 454 consecutive patients (male 71%, age 60.1 ± 10.9 years) were enrolled. Major complications occurred in 9 patients (2.0%): peripheral vascular complications were observed in 6 patients (1.3% per procedure), persistent phrenic nerve palsy occurred in 2 (0.4%), and transient ischemic attacks in 1 (0.2%). In both groups, the incidence of major complications was similar (group I [VKAs]: 7 patients [2.4%] vs group II [NOACs]: 2 patients [1.2%]; p = 0.5). In conclusion, CB ablation is a safe procedure for PV isolation and is associated with low complication rates. The incidence of adverse events in PV isolation using the second-generation CB with the periprocedural administration of NOACs is not significantly different than VKA treatment.

Topics: Ablation Techniques; Administration, Oral; Anticoagulants; Antithrombins; Atrial Fibrillation; Belgium; Cryosurgery; Dabigatran; Dose-Response Relationship, Drug; Drug Therapy, Combination; Factor Xa Inhibitors; Female; Follow-Up Studies; Humans; Incidence; Intraoperative Period; Italy; Male; Middle Aged; Postoperative Complications; Prognosis; Pyrazoles; Pyridines; Pyridones; Retrospective Studies; Rivaroxaban; Stroke; Survival Rate; Thiazoles; Time Factors; Vitamin K

Ablation of atrial fibrillation (AF) on uninterrupted phenprocoumon reduces periprocedural thromboembolic and bleeding complications. Heparin is administered intraprocedurally to achieve activated clotting times (ACT) of 300-400 seconds. We investigated the effect of international normalized ratio (INR) on ACT and intraprocedural heparin requirements. Moreover, safety of a target ACT of 250-300 seconds was investigated.. We studied 949 patients referred for AF or left atrial tachycardia ablation. Patients were divided into Group 1 (n = 249) with an INR <2 and Group 2 (n = 700) with an INR ≥2. Mean INR was 1.7 ± 0.13 in Group 1 and 2.3 ± 0.25 in Group 2. Baseline, mean, minimum and maximum ACT were significantly lower in Group 1 (138 ± 17 seconds vs. 145 ± 21 seconds; 281 ± 28 seconds vs. 288 ± 29 seconds; 251 ± 36 seconds vs. 258 ± 34 seconds; 307 ± 32 seconds vs. 316 ± 40 seconds; P <0.05). Intraprocedural heparin requirements adjusted to body weight were lower in Group 1 (127 ± 41 U/kg vs. 122 ± 40 U/kg). Weak correlations between INR and baseline, mean, minimum and maximum ACT as well as intraprocedural heparin requirements were observed. No differences regarding major or minor complications were found. INR and periprocedural anticoagulation parameters had no influence on major complications. No thromboembolic complications were observed in both groups with a target ACT value of 250-300 seconds.. There is only a weak correlation between INR, intraprocedural ACT, and intraprocedural heparin requirements. Periprocedural target ACT of 250-300 seconds seems safe and does not increase periprocedural bleeding and thromboembolic complications in patients undergoing RF ablation on uninterrupted phenprocoumon therapy.

Topics: Administration, Oral; Aged; Anticoagulants; Atrial Fibrillation; Blood Coagulation; Catheter Ablation; Electrocardiography; Female; Follow-Up Studies; Heart Atria; Hemorrhage; Humans; International Normalized Ratio; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Vitamin K

The number of patients using direct oral anticoagulants (DOACs) instead of vitamin K antagonists (VKA) is increasing and there is limited data on the safety of tooth extractions in patients taking DOACs. The aim of this study was to compare the amount of bleeding (AOB) and postoperative complications after tooth extractions between patients taking VKAs and patients taking DOACs without altering the anticoaguation therapy.. The study consisted of four groups: Direct thrombin inhibitor group, factor Xa inhibitor group, warfarin group and a control group. A single tooth was extracted in each patient and routine coagulation test values were recorded prior to extraction. AOB was measured for 20 minutes after tooth extraction. The patients were evaluated on 2nd and 7th days after extraction for bleeding. Status of bleeding was classified as no bleeding, mild bleeding controlled by gauze pads, moderate bleeding controlled by hemostatic agents and severe bleeding required hospitalization. Analysis of variance, chi square test and correlation analysis were used for statistical analysis of data.. A total of 84 patients (48 male, 36 female) were included in this study. The mean age of patients was 57 (38-87) years. Mean AOB was 1388.6±913.0, 1909.29±1063.1, 3673±1415.4, 1593.33±672.5 mg for direct thrombin inhibitor, factor Xa inhibitor, warfarin and control groups respectively. Mean AOB was significantly higher for warfarin group, compared to other groups (p<0.05). The number of patients showing mild and moderate bleeding was significantly higher in warfarin group compared to other groups on the 2nd postextraction day (p=0.001). No bleeding was occurred in control group on 2nd and 7th postextraction days and no bleeding was occurred in direct thrombin inhibitor group on 7th postextraction day. The number of bleeding events among groups was not statistically significant on 7th postextraction day (p=0.251).. Patients taking warfarin had more bleeding compared to patients taking direct oral anticoagulants after tooth extractions. In patients taking direct oral anticoagulants simple tooth extractions can be safely carried out without altering the anticaogulant regimen with the use of local hemostatic agents.

Topics: Administration, Oral; Adult; Aged; Aged, 80 and over; Anticoagulants; Female; Humans; Male; Middle Aged; Postoperative Complications; Postoperative Hemorrhage; Prospective Studies; Tooth Extraction; Vitamin K

Topics: Acute Coronary Syndrome; Administration, Oral; Anticoagulants; Atrial Fibrillation; Cerebral Hemorrhage; Consensus; Coronary Artery Disease; Drug Substitution; Fibrinolytic Agents; Gastrointestinal Hemorrhage; Hemorrhage; Humans; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Postoperative Complications; Risk Factors; Stents; Thrombosis; Vitamin K

Guidelines generally recommend oral anticoagulation to be considered the first 3 months after mitral valve repair based on small studies and consensus. However, in several studies no benefit of anticoagulation has been found.. From the national registries we identified all Danish patients who underwent mitral valve repair during the period between 1997 and 2012. Medication, hospitalisation and mortality data were studied. The association of use of vitamin K antagonists (VKAs) at discharge and risk of stroke/death was evaluated by means of Cox regression, landmark analyses and propensity matched models.. 2188 patients without prior VKA use, stroke or death day 7 after discharge were included and median follow-up was 4.9 years (0-13.7). 859 (39%) were discharged on VKAs and 523 (24%) experienced death or stroke, 60 of these occurred within the first 3 months and 24 between 3 and 6 months. Compared with patients without post-discharge VKA, patients on VKA had a lower risk of death/stroke at 3 months (HR=0.28, CI (0.13 to 0.62), p=0.002) and in the time period from 3 to 6 months (HR=0.85, CI (0.35 to 2.07), p=0.72). Risk of significant bleeding complications within 3 months were comparable in the two groups with 23 (2%) among patients without VKA and 6 (1%) among VKA-treated.. VKA treatment after mitral valve repair is associated with a markedly lower risk of adverse events as stroke or death without excess major bleeding risk during the first 3 months following surgery.

Topics: Adolescent; Adult; Aged; Anticoagulants; Atrial Fibrillation; Female; Heart Valve Diseases; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Mitral Valve; Postoperative Complications; Postoperative Hemorrhage; Risk Factors; Stroke; Vitamin K; Young Adult

To verify the rate of thromboembolic and hemorrhagic complications during the first 6 months after mitral valve repair and to assess whether the type of antithrombotic therapy influenced clinical outcome.. Retrospective data were retrieved from 19 centers. Inclusion criteria were isolated mitral valve repair with ring implantation. Exclusion criteria were ongoing or past atrial fibrillation and any combined intraoperative surgical procedures. The study cohort consisted of 1882 patients (aged 58 ± 15 years; 36% women), and included 1517 treated with an oral anticoagulant (VKA group) and 365 with antiplatelet drugs (APLT group). Primary efficacy outcome was the incidence of arterial thromboembolic events within 6 months and primary safety outcome was the incidence of major bleeding within 6 months. Propensity matching was performed to obtain 2 comparable cohorts (858 vs 286).. No differences were detected for arterial embolic complications in matched cohort (1.6% VKA vs 2.1% APLT; P = .50). Conversely, patients in the APLT group showed lower incidence of major bleeding complications (3.9% vs 0.7%; P = .01). Six-month mortality rate was significantly higher in the VKA group (2.7% vs 0.3%; P = .02). Multivariable analysis in the matched cohort found VKA as independent predictor of major bleeding complications and mortality at 6 months.. Vitamin K antagonist therapy was not superior to antiplatelet therapy to prevent thromboembolic complications after mitral valve repair. Our data suggest that oral anticoagulation may carry a higher bleeding risk compared with antiplatelet therapy, although these results should be confirmed in an adequately powered randomized controlled trial.

Topics: Administration, Oral; Adult; Age Factors; Aged; Anticoagulants; Cohort Studies; Databases, Factual; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Injections, Subcutaneous; Male; Middle Aged; Mitral Valve Insufficiency; Multivariate Analysis; Platelet Aggregation Inhibitors; Postoperative Complications; Predictive Value of Tests; Retrospective Studies; Risk Assessment; ROC Curve; Sex Factors; Statistics, Nonparametric; Survival Rate; Thromboembolism; Treatment Outcome; Ultrasonography; Vitamin K

A hereditary deficiency in coagulation factor VII (FVII) may affect the international normalized ratio (INR) value. However, FVII deficiency is occasionally associated with a tendency to bleed spontaneously. We hypothesized that perioperative substitution with coagulation factor concentrates might not be indicated in most patients.. In this retrospective data analysis, we included all patients with hereditary heterozygous FVII deficiency who underwent surgical procedures at the University Hospital Basel between December 2010 and November 2015. In addition, by searching the literature, we identified publications reporting patients with FVII deficiency undergoing surgical procedures without perioperative substitution.. We identified 22 patients undergoing 46 surgical procedures, resulting in a prevalence of 1:1500-2000. Coagulation factor concentrates were administered during the perioperative period in 15 procedures (33 %), whereas in the other 31 procedures (66 %), FVII deficiency was not substituted. No postoperative bleeding or thromboembolic events were reported. In addition, we found no differences in pre- and postoperative hemoglobin and coagulation parameters, with the exception of an improved postoperative INR value in the substituted group. In the literature review, we identified five publications, including 125 patients with FVII deficiency, undergoing 213 surgical procedures with no perioperative substitution.. Preoperative substitution using coagulation factor concentrates does not seem to be mandatory in patients with an FVII level ≥15 %. For decision-making on preoperative substitution, patient history of an increased tendency to bleed may be more important than the FVII level or increased INR value.

Topics: Adult; Aged; Factor VII; Factor VII Deficiency; Female; Heterozygote; Humans; International Normalized Ratio; Male; Middle Aged; Perioperative Care; Postoperative Complications; Postoperative Hemorrhage; Prevalence; Retrospective Studies; Thromboembolism; Vitamin K

Tooth extraction for patients treated by AVK and/or platelet aggregation inhibitor is performed according to local habits rather than to a consensus. We had for objective to assess hemorrhagic and thromboembolic risks for patients for whom treatment with AVK and/or platelet aggregation inhibitor was modified before tooth extraction.. Ninety-three patient files were examined retrospectively. The following data was collected: epidemiological data, ASA score, nature and changes of antithrombotic therapy, preoperative INR, number teeth extracted, postoperative complications (bleeding and thromboembolic events).. Thirty-seven patients were treated with oral anticoagulants, 41 by a platelet aggregation inhibitor, 10 by double platelet aggregation inhibitor therapy, and 5 by an AVK-platelet aggregation inhibitor combination. At D0, the mean INR was decreased to 1.4, 4 patients with high thromboembolic risk had received heparin relay treatment; the treatment was stopped for 9 of the 56 patients on monotherapy with antiplatelet therapy, 4 were switched from clopidogrel to lysine acetylate; clopidogrel was stopped for 7 patients under combination therapy. Seven hundred and twenty-six avulsions (mean 8.1 per patient) were performed, 41 patients presented with mild/moderate bleeding, easily resolved. A patient presented with delayed hemorrhage at D6 (AVK overdose). No thromboembolic complication was reported.. The modification of antithrombotic treatment, as for surgery at high risk of bleeding, seems to limit the risk of bleeding without increasing thromboembolic risk.

Topics: 4-Hydroxycoumarins; Adult; Aged; Aged, 80 and over; Female; Fibrinolytic Agents; Humans; Indenes; Male; Middle Aged; Postoperative Complications; Postoperative Hemorrhage; Retrospective Studies; Risk Factors; Thromboembolism; Tooth Extraction; Vitamin K

The study objective was to investigate the relationship between use of antithrombotic drugs and subarachnoid haemorrhage (SAH). We identified patients discharged from Danish neurosurgery units with a first-ever SAH diagnosis in 2000 to 2012 (n=5,834). For each case, we selected 40 age-, sex- and period-matched population controls. Conditional logistic regression models were used to estimate odds ratios (aOR), adjusted for comorbidity, education level, and income. Low-dose aspirin (ASA) use for < 1 month was associated with an increased risk of SAH (aOR 1.75, 95 % confidence interval [CI] 1.28-2.40). This aOR decreased to 1.26 (95 %CI: 0.98-1.63) with 2-3 months of ASA use, and approached unity with use for more than three months (1.11, 95 %CI 0.97-1.27). Analyses with first-time users confirmed this pattern, which was also observed for clopidogrel. ASA treatment for three or more years was associated with an aOR of SAH of 1.13 (95 %CI: 0.86-1.49). Short-term use (< 1 month) of vitamin K-antagonists (VKA) yielded an aOR of 1.85 (95 %CI 0.97-3.51) which dropped after 3+ years to 1.24, 95 %CI: 0.86-1.77. The risk of SAH was higher in subjects in dual antithrombotic treatment (aOR 2.08, 95 %CI: 1.26-3.44), and in triple antithrombotic treatment (aOR 5.74, 95 %CI: 1.76-18.77). In conclusion, use of aspirin,clopidogrel and VKA were only associated with an increased risk of SAH in the first three months after starting treatment. Long-term aspirin use carried no reduced SAH risk. Results should be interpreted cautiously due to their observational nature.

Topics: Aged; Aspirin; Case-Control Studies; Clopidogrel; Denmark; Drug Therapy, Combination; Female; Fibrinolytic Agents; Humans; Male; Middle Aged; Neurosurgical Procedures; Postoperative Complications; Risk; Subarachnoid Hemorrhage; Thrombosis; Ticlopidine; Vitamin K

Significant chronic subdural hematoma (CSDH) is usually a surgical emergency. Spontaneous resolution of CSDH has rarely been reported in the literature. We are reporting a case of spontaneous resolution of CSDH in a patient receiving anticoagulant therapy who had undergone mitral valve replacement surgery.

Topics: Adult; Anticoagulants; Antifibrinolytic Agents; Brain; Dexamethasone; Female; Glucocorticoids; Heart Valve Prosthesis Implantation; Hematoma, Subdural, Chronic; Humans; International Normalized Ratio; Mitral Valve Stenosis; Postoperative Complications; Tomography, X-Ray Computed; Treatment Outcome; Vitamin K; Withholding Treatment

Topics: Aged; Anesthesia, General; Anticoagulants; Appendicitis; Blood Coagulation Disorders; Blood Coagulation Factors; Cardiomyopathy, Dilated; Consciousness Disorders; Female; Heart Failure; Heart Ventricles; Heart-Assist Devices; Hemostatics; Humans; International Normalized Ratio; Male; Middle Aged; Postoperative Care; Postoperative Complications; Tomography, X-Ray Computed; Vitamin K

Topics: Administration, Oral; Aged; Antithrombins; Benzimidazoles; beta-Alanine; Contraindications; Dabigatran; Drug Substitution; Early Termination of Clinical Trials; Female; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Male; Middle Aged; Mitral Valve; Myocardial Infarction; Off-Label Use; Postoperative Complications; Pyridines; Randomized Controlled Trials as Topic; Stroke; Thromboembolism; Vitamin K

Venous thromboembolism (VTE) is a common complication in patients with cancer. Because of their improved subcutaneous bioavailability and reliable antithrombotic efficiency low-molecular-weight heparins (LMWH) are preferably used for prevention and treatment of cancer-related VTE. Thromboprophylaxis with LMWH is well established in patients undergoing cancer surgery and hospitalized cancer patients, while outpatient prophylaxis remains contentious. LMWH are recommended over unfractionated heparins and vitamin K antagonists for initial treatment and secondary prophylaxis (3-6 months) after cancer-related VTE. Long-term secondary prophylaxis should be considered for patients with ongoing active malignancy and low bleeding risk. Due to absence of clinical studies in cancer patients, the use of novel oral anticoagulants is currently not recommended.

Topics: Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Neoplasms; Postoperative Complications; Pulmonary Embolism; Randomized Controlled Trials as Topic; Risk Factors; Thrombocytopenia; Venous Thromboembolism; Vitamin K

The aim of the study was to determine whether patients treated with anticoagulants in the perioperative period are at higher risk of developing bleeding complications.. Medical records of patients operated for abdominal hernia were analysed. Data concerning demographic characteristic of a group, type of hernia, comorbidities, preoperative anticoagulation therapy and complications were collected. Association of applied anticoagulation therapy with the time of drainage, the amount of drained discharge and the length of hospitalisation was evaluated.. Analysed group consisted of 186 patients. Thirty seven patients were treated with different schemes of anticoagulant therapy before the the surgery. Patients treated with triple anticoagulation therapy (acetylsalicylic acid, low-molecular weight heparin, vitamin K antagonists) had significantly longer time of drainage in comparison to patients treated according to other schemes (p<0.05). The amount of drained discharge and time of hospitalisation did not differ significantly. Neither comorbidities nor the administration of low-molecular weight heparin did not affect the analysed parameters.. Patients operated on abdominal hernia, who were treated with triple anticoagulation therapy in peri-operative period, require significantly longer drainage of the wound what can result in prolonged hospitalisation.

Topics: Adult; Aged; Anticoagulants; Aspirin; Blood Coagulation Disorders; Drainage; Female; Hemorrhage; Heparin, Low-Molecular-Weight; Hernia, Abdominal; Hospitalization; Humans; Male; Middle Aged; Perioperative Period; Poland; Postoperative Complications; Risk Factors; Vitamin K

Oral anticoagulant therapy is currently performed using vitamin K-dependent (VKA) or novel, non-vitamin-K-dependent (NOAC) anticoagulants. Patients can thus be involved into the decision process which type of anticoagulants to use. Preference of patients for a specific type of anticoagulants is included in several international guidelines for prophylaxis of embolic events in patients with atrial fibrillation.. Description of the development of a short questionnaire to identify this preference in patients treated with VKA.. Using the questionnaires Freiburger personality inventory (FPI-R), health survey SF-12, State-Trait Anxiety Inventory (STAI) and a self-developed questionnaire on anticoagulant therapy, multiple regression analysis identified 7 items for the willingness of patients to change anticoagulation from VKA to NOAC with a probability of about 90%.. Further investigations have to be performed to identify the preference of patients for anticoagulation with VKA using this short questionnaire.

Topics: Administration, Oral; Adult; Anticoagulants; Character; Drug Substitution; Drugs, Investigational; Female; Humans; Injections, Subcutaneous; Male; Patient Preference; Personality Inventory; Postoperative Complications; Psychometrics; Reproducibility of Results; Risk Factors; Surveys and Questionnaires; Thromboembolism; Vitamin K

Vitamin K antagonists not only influence the synthesis of coagulation factors but also the activation of other vitamin K dependent proteins. Among other possible side effects, arterial calcification has been focused on in recent years.. Four patients under long-term anticoagulation for more than 10 years developed medial calcific sclerosis. In case 1 we identified an unexplained medial calcific sclerosis on x-ray after a trauma by chance. After that we examined the ankle-brachial index of blood pressure in all patients who had received long-term anticoagulation for more than 10 years. Where the index exceeded 1,3 we performed a x-ray-examination of the forefoot. Of the four described patients no one suffered from diabetes mellitus, renal failure or hyperparathyreoidism. Serum calcium was normal in all patients. The severity of the medial calcific sclerosis could not be explained by the initial vascular risk factors.. In certain patients, even at low vascular risk, a medial calcific sclerosis can appear under long-term anticoagulation with vitamin K antagonists. We conclude that vitamin K antagonists inhibit several proteins which protect the vessels from calcification leading to medial calcific sclerosis.

Topics: Aged; Aged, 80 and over; Ankle Brachial Index; Anticoagulants; Atrial Fibrillation; Coronary Artery Disease; Forefoot, Human; Heart Valve Prosthesis Implantation; Humans; Incidental Findings; Long-Term Care; Male; Middle Aged; Monckeberg Medial Calcific Sclerosis; Phenprocoumon; Postoperative Complications; Vitamin K

Topics: Aged; Anticoagulants; Antitubercular Agents; Comorbidity; Cyclosporine; Drug Substitution; Drug Therapy, Combination; Female; Hemorrhage; Heparin; Humans; Immunosuppressive Agents; Kidney Transplantation; Lung Diseases, Interstitial; Pericarditis; Phenindione; Polypharmacy; Postoperative Complications; Rifampin; Sirolimus; Venous Thrombosis; Vitamin K

This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure.. The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement.. In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C).. Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.

Topics: Angioplasty, Balloon, Coronary; Aspirin; Atrial Fibrillation; Drug Administration Schedule; Elective Surgical Procedures; Evidence-Based Medicine; Fibrinolytic Agents; Heart Valve Prosthesis; Humans; Perioperative Care; Platelet Aggregation Inhibitors; Postoperative Complications; Risk Factors; Societies, Medical; Stents; Thrombosis; United States; Vitamin K

Antithrombotic therapy in valvular disease is important to mitigate thromboembolism, but the hemorrhagic risk imposed must be considered.. The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.. In rheumatic mitral disease, we recommend vitamin K antagonist (VKA) therapy when the left atrial diameter is > 55 mm (Grade 2C) or when complicated by left atrial thrombus (Grade 1A). In candidates for percutaneous mitral valvotomy with left atrial thrombus, we recommend VKA therapy until thrombus resolution, and we recommend abandoning valvotomy if the thrombus fails to resolve (Grade 1A). In patients with patent foramen ovale (PFO) and stroke or transient ischemic attack, we recommend initial aspirin therapy (Grade 1B) and suggest substitution of VKA if recurrence (Grade 2C). In patients with cryptogenic stroke and DVT and a PFO, we recommend VKA therapy for 3 months (Grade 1B) and consideration of PFO closure (Grade 2C). We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). In the first 3 months after bioprosthetic valve implantation, we recommend aspirin for aortic valves (Grade 2C), the addition of clopidogrel to aspirin if the aortic valve is transcatheter (Grade 2C), and VKA therapy with a target international normalized ratio (INR) of 2.5 for mitral valves (Grade 2C). After 3 months, we suggest aspirin therapy (Grade 2C). We recommend early bridging of mechanical valve patients to VKA therapy with unfractionated heparin (DVT dosing) or low-molecular-weight heparin (Grade 2C). We recommend long-term VKA therapy for all mechanical valves (Grade 1B): target INR 2.5 for aortic (Grade 1B) and 3.0 for mitral or double valve (Grade 2C). In patients with mechanical valves at low bleeding risk, we suggest the addition of low-dose aspirin (50-100 mg/d) (Grade 1B). In valve repair patients, we suggest aspirin therapy (Grade 2C). In patients with thrombosed prosthetic valve, we recommend fibrinolysis for right-sided valves and left-sided valves with thrombus area < 0.8 cm(2) (Grade 2C). For patients with left-sided prosthetic valve thrombosis and thrombus area ≥ 0.8 cm(2), we recommend early surgery (Grade 2C).. These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk.

Topics: Aspirin; Catheterization; Combined Modality Therapy; Ductus Arteriosus, Patent; Evidence-Based Medicine; Fibrinolytic Agents; Heart Atria; Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Humans; Mitral Valve; Platelet Aggregation Inhibitors; Postoperative Complications; Rheumatic Heart Disease; Risk Factors; Societies, Medical; Stroke; Thromboembolism; Thrombolytic Therapy; Thrombosis; Vitamin K

We report a case of fat-soluble vitamin deficiency in a 14-year old boy who had chronic duodenal obstruction. He presented with periodic unexplained bleeding tendency. The laboratory results showed positive fat globules in stool and prolonged prothrombin time. His further investigation revealed low plasma vitamin A and undetectable plasma vitamin E. After parenteral vitamin K and oral vitamin A and E supplement, these abnormalities resolved although he still had absent knee jerk. We propose that fat malabsorption and fat-soluble vitamin deficiency can occur after prolonged duodenal obstruction that induce bacterial overgrowth following by bile acid deconjugation. Despite very few case reports, screening for fat malabsorption and fat-soluble vitamin deficiency might be warranted in patients with chronic small bowel obstruction.

Topics: Adolescent; Delayed Diagnosis; Duodenal Obstruction; Gastric Bypass; Hemorrhage; Humans; Infusions, Parenteral; Male; Postoperative Complications; Reoperation; Steatorrhea; Treatment Outcome; Vitamin K; Vitamin K Deficiency

Vitamin K antagonists (VKAs) are widely used in thromboembolic diseases. We report five cases of necrotic leg ulcers having a particularly severe course and in which withdrawal of VKA treatment alone enabled healing.. Five patients presented with necrotic leg ulcers clinically evocative of necrotic angiodermatitis or vasculitis. Histological features were variable, including inconstantly inflammatory lesions (leukocytoclastic vasculitis) and microthrombosis. None of the patients had laboratory signs of autoimmune disease. Healing occurred in all patients only after withdrawal of VKA therapy (fluindione or acenocoumarol). Associated vascular diseases included superficial venous, distal arterial insufficiency and postphlebitic disease. In three cases, thrombotic factors were observed: hyperhomocysteinaemia or heterozygous Factor V Leiden mutation.. Although the causative role of VKAs is based solely on chronological criteria, this potential side effect deserves publication because of its practical therapeutic consequences. The physiopathological mechanisms accounting for the role of VKAs, including immunoallergic phenomena and, above all, microcirculatory thrombotic processes, are hypothetical and not universally accepted.

Topics: Acenocoumarol; Activated Protein C Resistance; Aged; Aged, 80 and over; Anticoagulants; Diabetic Angiopathies; Factor V; Female; Humans; Hyperhomocysteinemia; Leg Ulcer; Male; Necrosis; Phenindione; Polyarteritis Nodosa; Postoperative Complications; Purpura; Thrombophilia; Varicose Ulcer; Vasculitis, Leukocytoclastic, Cutaneous; Vitamin K

Patients with prosthetic heart valves require lifelong anticoagulation to prevent thromboembolism. When they have intracranial haemorrhage, anticoagulation has to be withheld. This study was aimed to identify safety duration and complications of anticoagulation withholding in patients with prosthetic heart valves and intracranial haemorrhage. This was a retrospective descriptive study in 26 prosthetic heart valve patients hospitalised in Srinagarind Hospital, Khon Kaen University because of intracranial haemorrhage from 2003 to 2008. Range of anticoagulation withholding was 1 to 26 days with mean 8.5 ± 7.7 days. Most patients (84.6%) were withheld anticoagulation for less than 14 days. There were five in-hospital deaths mostly within 3 days of admission from severe intracranial haemorrhage. No data of reintroduction of anticoagulation was found in three patients because they were lost to follow up. One patient had right basal ganglia infarction after 7 days of anticoagulation withholding. Prosthetic heart valve dysfunction was suspected in one patient who withheld anticoagulant for 76 days. Discontinuation of anticoagulation in patients with prosthetic heart valves and intracranial haemorrhage for less than 7 days was associated with low thromboembolic risk and there was no clinical evidence of prosthetic heart valve dysfunction when anticoagulation was withheld for less than 14 days.

Topics: Adult; Anticoagulants; Aspirin; Atrial Fibrillation; Combined Modality Therapy; Comorbidity; Contraindications; Craniotomy; Female; Heart Valve Prosthesis; Humans; International Normalized Ratio; Intracranial Hemorrhages; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Thailand; Thromboembolism; Time Factors; Vitamin K; Warfarin

During the past five decades, anticoagulant therapy has consisted of rapidly acting parenteral drugs (unfractionated heparin [UFH] low-molecular-weight heparins [LMWH]) for prevention of venous thromboembolism and initial treatment of arterial and venous thromboembolism, whereas vitamin K antagonists (VKA) are used for longer term oral treatment. These drugs act by indirectly inhibiting several activated plasma clotting factors (UFH, LMWH) or by blocking the synthesis of some of them (VKA). In recent years, compounds that specifically block activated coagulation factor X (FXa) or thrombin have been developed. Thus, fondaparinux, and its long-acting derivative idraparinux, are administered subcutaneously. These substances inhibit F Xa indirectly via antithrombin. Small molecules have also been developed that directly block FXa (rivaroxaban, apixaban) or thrombin (dabigatran etexilate) following oral administration. In the present review we discuss the currently available evidence supporting the use of these new anticoagulants, in particular rivaroxaban and dabigatran etexilate, in the setting of thromboprophylaxis following major orthopaedic surgery, and the broader perspectives that these new drugs may open up in the next few years.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Benzimidazoles; Dabigatran; Heparin; Heparin, Low-Molecular-Weight; Humans; Morpholines; Orthopedic Procedures; Postoperative Complications; Pyridines; Rivaroxaban; Thiophenes; Thromboembolism; Thrombolytic Therapy; Vitamin K

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggestions imply that individual patient values may lead to different choices (for a full discussion of the grading, see the "Grades of Recommendation" chapter by Guyatt et al). Among the key recommendations in this chapter are the following: we recommend that every hospital develop a formal strategy that addresses the prevention of VTE (Grade 1A). We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A), and we recommend that mechanical methods of thromboprophylaxis be used primarily for patients at high bleeding risk (Grade 1A) or possibly as an adjunct to anticoagulant thromboprophylaxis (Grade 2A). For patients undergoing major general surgery, we recommend thromboprophylaxis with a low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH), or fondaparinux (each Grade 1A). We recommend routine thromboprophylaxis for all patients undergoing major gynecologic surgery or major, open urologic procedures (Grade 1A for both groups), with LMWH, LDUH, fondaparinux, or intermittent pneumatic compression (IPC). For patients undergoing elective hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or a vitamin K antagonist (VKA); international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0 (each Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1B), a VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 1B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty or HFS receive thromboprophylaxis for a minimum of 10 days (Grade 1A); for hip arthroplasty and HFS, we recommend continuing thromboprophylaxis > 10 days and up to 35 days (Grade 1A). We recommend that all major trauma and all spinal cord injury (SCI) patients receive thromboprophylaxis (Grade 1A). In patients admitted to hospital with an acute medical illness, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (each Grade 1A). We recommend that, on admission to the ICU, all patients be assessed for their risk of VTE, and th

Topics: Anticoagulants; Drug Therapy, Combination; Evidence-Based Medicine; Fondaparinux; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Polysaccharides; Postoperative Complications; Risk Assessment; Venous Thromboembolism; Vitamin K

Transesophageal echocardiography (TEE) has been used to document the incidence of non-obstructive thrombosis (NOT) after mechanical prosthetic mitral valve replacement (MVR). The postoperative occurrence and unpredictable evolution of NOT complicate its management. The study aim was to examine the safety and efficacy of prolonged, combined administration of heparin and vitamin K antagonists (VKA) recommended for this indication.. All patients who underwent mechanical prosthetic MVR between July 1999 and December 2004 at the authors' institution were systematically studied with TEE immediately after surgery. Patients who presented with > or = 5 mm NOT were treated with combined heparin and VKA until TEE-confirmed resolution of the thrombus.. Among 256 patients who underwent 263 MVRs (seven reinterventions), 47 (17.9%) presenting with > or = 5 mm NOT received combined heparin and VKA for between 7 and 115 days (median 17 days). No thromboembolic or hemorrhagic events or deaths were observed during this period of observation. Four patients were treated with danaparoid and VKA because of thrombocytopenia induced by heparin before the diagnosis of NOT. Over a mean follow up of 39 months, one patient died from cancer and another from the sequelae of a stroke. In total, there were five NOT recurrences, three of which were complicated by embolic events without sequelae within eight months, and one by a recurrent stroke. In addition, three patients without demonstrable NOT recurrence suffered transient ischemic attacks.. Among this small sample of patients, combined heparin and VKA was well tolerated and effective, and could prevent reoperation or thrombolysis. These observations may warrant further study in a larger patient population.

Topics: Adult; Aged; Anticoagulants; Cause of Death; Drug Therapy, Combination; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Heparin; Humans; Long-Term Care; Male; Middle Aged; Mitral Valve; Postoperative Complications; Stroke; Thrombosis; Vitamin K

Topics: Angioplasty, Balloon; Anticoagulants; Atherosclerosis; Combined Modality Therapy; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hypolipidemic Agents; Meta-Analysis as Topic; Peripheral Vascular Diseases; Platelet Aggregation Inhibitors; Postoperative Complications; Randomized Controlled Trials as Topic; Risk Factors; Stents; Vascular Patency; Vascular Surgical Procedures; Vitamin K

Topics: Anticoagulants; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Orthopedic Procedures; Postoperative Complications; Risk; Vitamin K

All 110 Dutch orthopedic departments were sent a survey on perioperative thromboprophylaxis protocols, and 79% responded. After hip and knee replacements, all used pharmacological thromboprophylaxis: a low-molecular weight heparin (LMWH) in 87% of departments, which was most often combined with vitamin K antagonists (VKAs). LMWH was usually started preoperatively (91%). After discharge, VKAs were mostly prescribed (79%) for at least 6 weeks, and often for 3 months. 17% of departments used LMWH for 6 weeks, whereas in only 3% no post-discharge prophylaxis was given. In day-care surgery, including arthroscopies, 58% use LMWH and in short-stay surgery 80% administer LMWH during the hospital stay. Because of lack of conclusive evidence for day-care surgery, the national guidelines cannot support pharmacological prophylaxis in this setting. In general, Dutch orthopedic departments comply poorly with the national guidelines on extended thromboprophylaxis for hip and knee replacement surgery, which recommends postoperative LMWH for 6 weeks. They are divided in the use of pharmacological prophylaxis in day-care surgery.

Topics: Fibrinolytic Agents; Guideline Adherence; Heparin, Low-Molecular-Weight; Humans; Netherlands; Postoperative Complications; Practice Guidelines as Topic; Surveys and Questionnaires; Thrombosis; Vitamin K

The management of patients admitted with a fracture requiring surgery who are taking warfarin anticoagulation is unclear. We examined the anticoagulation management for 33 hip fracture patients on warfarin at the time of admission. Hospital course and complications were recorded on all patients. The mean INR on admission was 3.2 and prior to surgery 2.2. Eight patients (24%) had percutaneous cancellous screws for an intracapsular fracture regardless of the admission INR. In 21 (64%) patients, surgery was delayed whilst the INR came down, with an average delay of 72 h from admission to surgery. No specific treatment to lower the INR, other than wait and watch policy adopted in 11 (33%) of these patients. Pharmacological methods used to reduce the INR were fresh frozen plasma in nine cases, and intravenous Vitamin K in four patients. One patient died from post-operative haematemesis and three died from medical complications unrelated to the warfarin therapy. There were no wound haematomas or other bleeding complications. Delaying surgery whilst waiting for the INR to fall to acceptable levels may result in significant delays to surgery and we would recommend a more aggressive policy to enable earlier surgery.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Atrial Fibrillation; Female; Hip Fractures; Humans; International Normalized Ratio; Male; Middle Aged; Plasma; Postoperative Complications; Preoperative Care; Prospective Studies; Risk Factors; Time Factors; Vitamin K; Warfarin

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

Topics: Aged; Aminocaproic Acid; Antifibrinolytic Agents; Autoantibodies; Humans; IgA Vasculitis; Male; Myeloproliferative Disorders; Postoperative Complications; Prothrombin; Vitamin K

To investigate the relationship among lipids, coagulation and thrombosis in the absence of atherosclerosis, spontaneous or dietary-induced hyperlipidemic (FHL) rats were studied. FHL showed higher levels of coagulation factors VII, IX, X, VIII and XII and a shortening of the occlusion time (OT) of an artificial arterial prosthesis as compared with normolipidemic (FNL) animals. Damage of abdominal aorta of FHL was followed by increased fibrin deposition in the vascular intima as compared to FNL. After 5 months of cholesterol-rich diet FNL showed increased cholesterol, triglycerides and factor II, VII, IX, X, XII levels. A significant shortening of the OT and increased fibrin deposition was also observed. Two-month diet withdrawal restored the initial condition. Warfarin treatment, at a dose decreasing vitamin K-dependent factor to levels found in FNL, prolonged the OT and reduced fibrin deposition, without modifying F XII or changing lipid profile. An increase in the activated form of F VII was observed. In contrast, no difference was found in F VII clearance. High lipid levels favour the process of thrombus formation by increasing the activation of vitamin K-dependent coagulation factors. Low-dose warfarin treatment reverts the prothrombotic effect of hyperlipidemia.

Topics: Administration, Oral; Animals; Anticoagulants; Aorta, Abdominal; Aortic Diseases; Blood Coagulation Factors; Blood Vessel Prosthesis; Cholesterol, Dietary; Diet, Atherogenic; Disease Models, Animal; Enzyme Activation; Factor VII; Hypercholesterolemia; Hyperlipidemias; Hypertriglyceridemia; Postoperative Complications; Rats; Rats, Inbred Strains; Rats, Sprague-Dawley; Thrombophilia; Thrombosis; Vitamin K; Warfarin

A 87-year-old patient developed coagulation abnormality following hip surgery related to the prophylactic use of cefamandole. Cefamandole as others cephalosporins with a methyl-tetrazol-thiol lateral chain interferes with the vitamin K regeneration cycle as do oral anticoagulants. Therefore, the use of others antibiotics or systematic vitamin K1 supplementation or single dose of cefamandole is recommended for patients with renal failure or with malnutrition. Vitamin K1 supplementation is a simple method resulting in complete resolution of the coagulation disorder.

Topics: Aged; Aged, 80 and over; Antibiotic Prophylaxis; Arthroplasty, Replacement, Hip; Cefamandole; Cephalosporins; Female; Femoral Neck Fractures; Hematoma; Hemorrhagic Disorders; Humans; Postoperative Complications; Vitamin K; Vitamin K Deficiency

Vitamin K deficiency is a common occurrence in the surgical and intensive care unit population, but its incidence in kidney and combined kidney-pancreas allograft recipients has not been described. We report four patients who received cadaveric kidney or combined kidney-pancreas allografts and subsequently developed significant bleeding associated with deficiency of vitamin K. Their coagulopathy promptly resolved with the parenteral administration of vitamin K. Treatment with vitamin K should be considered in kidney or combined kidney-pancreas allograft recipients with a prolonged prothrombin or partial thromboplastin time during the first postoperative week to avoid hemorrhagic complications.

Topics: Adult; Aged; Blood Coagulation Tests; Female; Hemorrhage; Humans; Kidney Transplantation; Male; Middle Aged; Pancreas Transplantation; Postoperative Complications; Vitamin K; Vitamin K Deficiency

A 76-year-old man under long term oral anticoagulant treatment showed unclottable prothrombin time (PT) without overt bleeding. After oral administration of vitamin K1, PT remained severely prolonged and the patient was hospitalized. INR was 8.0 and responded to parenteral vitamin K. Cholestasis resulting in poor intestinal vitamin K resorption was assumed to have caused "overanticoagulation". Quick test is a global clotting test for the extrinsic and common pathways of the coagulation system. Increased PT, i.e. decreased Quick percentage, may be due to different conditions and should--if unexplained--be further analyzed by assaying factors II, V, VII, X and fibrinogen. Preanalytical problems, plasma dilution with clotting factor-free volume replacement, decreased vitamin K-dependent clotting factors (oral anticoagulation, intoxication with certain rodenticides, vitamin K deficiency), impaired liver synthetic capacity, disseminated intravascular coagulation, or massive heparin contamination may cause prolonged PT. Newborns physiologically have longer PT and should receive vitamin K prophylaxis.

Topics: Administration, Oral; Aged; Anticoagulants; Blood Coagulation Tests; Cholestasis, Intrahepatic; Diagnosis, Differential; Heart Valve Prosthesis Implantation; Hemorrhagic Disorders; Humans; International Normalized Ratio; Male; Phenprocoumon; Postoperative Complications; Vitamin K

Deficiencies of the vitamin K-dependent coagulation factors were identified in a Devon rex cat which had bled after castration. Haemorrhage was controlled by plasma transfusion. Clotting times were normalised by oral administration of vitamin K. This report confirms the existence of this bleeding disorder in a Devon rex cat in the United Kingdom.

Topics: Administration, Oral; Animals; Blood Coagulation; Blood Coagulation Disorders; Blood Coagulation Factors; Castration; Cat Diseases; Cats; Hemorrhage; Male; Partial Thromboplastin Time; Postoperative Complications; Prothrombin Time; Vitamin K; Vitamin K Deficiency

The high incidence of thromboembolic complications in orthopedic surgery necessitates an effective thromboprophylactic regime. Current methods of prophylaxis are discussed, and principles of thromboprophylaxis with low-molecular weight heparin are presented.

Topics: Aspirin; Bandages; Combined Modality Therapy; Dextrans; Drug Therapy, Combination; Heparin; Humans; Orthopedics; Postoperative Complications; Thromboembolism; Vitamin K

The correlation between the dose of menatetrenone and the incidence of post-laparotomy peritoneal adhesion in Ryan's model was investigated with the use of rats. In the menatetrenone treated group, the menatetrenone was intramuscularly given in a dosage of 10 mg immediately after closure of the abdominal wound and every 24 hours for two days. In this group, the incidence of ceco-colonic adhesion was 54% (20/37), whereas the incidence in non-treated group was 26% (10/39) (p less than 0.012). Especially in cases with an air-drying time of 1-2 minutes, the difference between incidences of ceco-colonic adhesion in the menatetrenone and that of the non-treated group was high. The former incidence was 61% (17/28) and that of the latter was 21% (6/29) (p less than 0.01). In addition, the incidence of peritoneal adhesion was proportionally dose-dependent to the menatetrenone. In our clinical retrospective study, the incidence of post-gastrectomy adhesive ileus increased with menatetrenone treatment to a significant degree. It is concluded that prophylactic administration of a large dose of menatetrenone should be avoided, because the incidence of post-laparotomy peritoneal adhesion could be increased.

Topics: Animals; Hemostatics; Intestinal Diseases; Intestinal Obstruction; Male; Peritoneal Diseases; Postoperative Complications; Rats; Rats, Inbred Strains; Tissue Adhesions; Vitamin K; Vitamin K 2

Topics: Adult; Aged; Female; Hip Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Thrombosis; Vitamin K

Among the various methods to diagnose deep venous thrombosis in the lower limbs, the radiofibrinogen uptake test has been mainly used in clinical studies. Physical means to accelerate venous return are of limited use and only in patients at a low thrombotic risk. Antivitamins K are efficient, but surgeons hesitate to use them because of the postoperative hemorrhagic risk. Dextran infusions are quite effective and without real risk of bleeding. The same holds for low dose heparin administered subcutaneously, particularly when combined with dihydroergotamine. Among the various anti-aggregating agents only aspirin may be effective in the prevention of venous thrombosis.

Topics: Blood Circulation; Dextrans; Humans; Platelet Aggregation; Postoperative Complications; Pulmonary Embolism; Thrombophlebitis; Vitamin K

Topics: Blood Coagulation; Heparin; Humans; Platelet Aggregation; Postoperative Complications; Risk; Thrombophlebitis; Vitamin K

A patient underwent end-to-side jejunoileostomy for morbid obesity, and 3 years later an end-to-end jejunoileostomy with ileotransversostomy was performed. Nine years later she presented with night blindness, severe diarrhea and mild jaundice and was found to have malabsorption with vitamin A and K deficiencies as well as asymptomatic liver cirrhosis. Her shunt was removed, and a gastric partition was performed. The night blindness and abnormal prothrombin time were corrected by the administration of vitamins A and K. This case demonstrates that complications may appear many years after jejunoileal bypass surgery, and therefore, the patients should remain under strict medical supervision indefinitely.

Topics: Female; Humans; Ileum; Jejunum; Liver Cirrhosis; Middle Aged; Night Blindness; Obesity; Postoperative Complications; Reoperation; Vitamin A; Vitamin K

An analysis of case histories of 225 patients with bronchiectasis subjected to lung resections of various volume has shown high efficiency of isolated and associated resection of the basal pyramid with an intact apical segment. The apical segment remaining intact gives positive effects on the rearrangement of the architectonics of the bronchial tree preventing a considerable displacement of the remaining bronchi. The postoperative period in the patients who had an additional treatment of the wound surface of the sixth segment was more favorable as compared with the patients with open wounds.

Topics: Adult; Bronchiectasis; Cyanoacrylates; Embolization, Therapeutic; Female; Follow-Up Studies; Hemostasis, Surgical; Humans; Male; Pleura; Pneumonectomy; Postoperative Complications; Time Factors; Vitamin K; Vitamin K 2

Topics: 4-Hydroxycoumarins; Aged; Anticoagulants; Female; Heparin; Hip Prosthesis; Humans; Indenes; Male; Middle Aged; Platelet Aggregation; Postoperative Complications; Thromboembolism; Vitamin K

Topics: Dextrans; Heparin; Humans; Postoperative Complications; Pulmonary Embolism; Vitamin K

Topics: Acenocoumarol; Adolescent; Adult; Aged; Aortic Valve; Dipyridamole; Drug Therapy, Combination; Embolism; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Vitamin K

Topics: Anticoagulants; Heart Valve Prosthesis; Humans; Postoperative Complications; Prothrombin Time; Vitamin K; Warfarin

Topics: 4-Hydroxycoumarins; Anticoagulants; Heart Valve Prosthesis; Humans; Indenes; Postoperative Complications; Thrombosis; Vitamin K

Topics: Adult; Denmark; Female; Heparin; Humans; Middle Aged; Postoperative Complications; Surveys and Questionnaires; Thrombophlebitis; Vitamin K

Topics: Animals; Blood Coagulation Factors; Humans; Postoperative Complications; Rabbits; Vitamin K

Three groups of patients undergoing urological operations were given a prophylactic regimen of either subcutaneous heparin (n = 1143), antiprothrombics (n = 944) or no medication (n = 570). Results were deemed through simple clinical criteria. They were similar for the whole of patients and for some types of surgery, pecularly protatic: Anticoagulation induced a significant lowering of the frequency of thromboembolism, heparin being more efficient than antiprothrombics. It does not increase the percentage of haemorrhages. More, peridural anesthesia is not contre-indicated by heparin. However, parietal problems appear to be more frequent among heparinized patients.

Topics: Adolescent; Age Factors; Aged; Hemorrhage; Heparin; Humans; Male; Middle Aged; Postoperative Complications; Prostatic Hyperplasia; Retrospective Studies; Thromboembolism; Urinary Tract; Vitamin K

The authors analyzed the progress in the prevention of thrombo-embolic risk in 550 pneumonectomies divided chronologically in 4 groups : without anticoagulant treatment, with post-operative anti-vitamin K, with post-operative calcium heparinate, with pre and post-operative calcium heparinate. This study revealed the necessity of a pre-operative systematic preventive treatment : systematic, as there is no biological reason enabling the prevention of thrombosis risk. Pre-operative, because venous thrombosis and pulmonary embolism can occur very early.

Topics: Heparin; Humans; Pneumonectomy; Postoperative Care; Postoperative Complications; Preoperative Care; Risk; Thromboembolism; Vitamin K

The management of patients who require surgery while being treated with oral anticoagulants is a difficult balance between the risks of bleeding and those of recurrent thromboembolism. The urgency and the extent and site of surgery are important considerations, as are the strength of the indication for anticoagulants and the degree of anticoagulation. A practical approach is outlined for various situations that may be encountered.

Topics: Administration, Oral; Blood Transfusion; Hemorrhage; Heparin; Humans; Intraoperative Care; Postoperative Care; Postoperative Complications; Preoperative Care; Prothrombin Time; Thrombophlebitis; Vitamin K; Warfarin

Topics: Adolescent; Adult; Aged; Anticoagulants; Female; Femoral Neck Fractures; Femur Head; Heparin; Hip Fractures; Humans; Male; Middle Aged; Postoperative Complications; Vitamin K

Topics: Dextrans; Heparin; Humans; Platelet Aggregation; Postoperative Complications; Pulmonary Embolism; Thrombophlebitis; Vitamin K

Topics: Aged; Anticoagulants; Arthritis, Rheumatoid; Arthroplasty; Aspirin; Blood Coagulation; Blood Platelets; Dextrans; Follow-Up Studies; Heparin; Hip Joint; Humans; Joint Prosthesis; Osteoarthritis; Postoperative Complications; Spondylitis, Ankylosing; Vitamin K; Warfarin

Topics: Heparin; Male; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Thrombophlebitis; Urologic Diseases; Vitamin K

Topics: Aged; Blood Coagulation; Calcium; Female; Hemorrhage; Heparinoids; Humans; Injections, Subcutaneous; Middle Aged; Myocardial Infarction; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Time Factors; Urologic Diseases; Vitamin K

Topics: Ascorbic Acid; Fructose; Glucose; Humans; Magnesium; Parenteral Nutrition; Phosphates; Postoperative Complications; Potassium; Shock; Sodium; Sorbitol; Vitamin A; Vitamin B Complex; Vitamin D; Vitamin K; Vitamins; Xylitol; Zinc

Topics: Anesthesia, Endotracheal; Bile Ducts; Biliary Tract Diseases; Cholangitis; Female; Humans; Hypoprothrombinemias; Infant; Infant, Newborn; Infant, Newborn, Diseases; Japan; Jaundice, Neonatal; Liver Transplantation; Male; Methods; Postoperative Complications; Preoperative Care; Transplantation, Homologous; Vitamin K

Topics: Aged; Cholelithiasis; Crohn Disease; Diarrhea; Female; Gastrointestinal Agents; Humans; Ileum; Ischemia; Kidney Calculi; Lignin; Malabsorption Syndromes; Male; Mesentery; Middle Aged; Postoperative Complications; Preoperative Care; Vitamin A; Vitamin B 12; Vitamin D; Vitamin K

Topics: Blood Coagulation; Blood Coagulation Disorders; Embolism; Factor X; Heparin; Humans; Injections, Subcutaneous; Postoperative Complications; Thromboembolism; Thrombosis; Urogenital System; Vitamin K

Topics: Adolescent; Adult; Anticoagulants; Blood Coagulation Tests; Child; Female; Heart Valve Diseases; Heart Valve Prosthesis; Hemodynamics; Hemolysis; Heparin; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Sepsis; Thromboembolism; Vitamin K

Topics: Biliary Fistula; Colonic Diseases; Feces; Humans; Intestinal Fistula; Lipid Metabolism; Malabsorption Syndromes; Male; Middle Aged; Postoperative Complications; Vitamin K; Vitamin K Deficiency

Topics: Adenoidectomy; Child; Child, Preschool; Deficiency Diseases; Female; Hemorrhage; Humans; Male; Postoperative Complications; Preoperative Care; Prothrombin Time; Tonsillectomy; Vitamin K

Topics: Aneurysm; Animals; Aortic Aneurysm; Aortography; Arteries; Arteriosclerosis; Arteriosclerosis Obliterans; Blood Coagulation; Blood Vessel Prosthesis; Dextrans; Dicumarol; Dogs; Female; Fibrinolytic Agents; Heparin; Humans; Male; Methods; Nylons; Phenindione; Plastics; Postoperative Complications; Suture Techniques; Thrombosis; Vascular Surgical Procedures; Vitamin K

Topics: Blood Coagulation Tests; Coumarins; Heparin; Humans; Massage; Postoperative Complications; Thrombosis; Vascular Resistance; Vitamin K

Topics: Age Factors; Bilirubin; Blood Coagulation; Blood Glucose; Blood Proteins; Blood Transfusion; Carbohydrate Metabolism; Carcinoma, Hepatocellular; Child; Female; Hepatectomy; Humans; Hyperbilirubinemia; Infant; Infusions, Parenteral; Liver Neoplasms; Male; Postoperative Care; Postoperative Complications; Prothrombin Time; Serum Albumin; Vitamin K; Vitamin K Deficiency

Topics: Anticoagulants; Blood Coagulation Tests; Fibrinolytic Agents; Humans; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Thrombophlebitis; Thrombosis; Vitamin K

Topics: Anticoagulants; Blood Coagulation Tests; Humans; Male; Medication Errors; Middle Aged; Postoperative Complications; Prothrombin Time; Thromboembolism; Vitamin K

Topics: Adenoidectomy; Adolescent; Blood Coagulation Factors; Child, Preschool; Female; Hemorrhage; Hemostasis, Surgical; Humans; Male; Partial Thromboplastin Time; Platelet Count; Postoperative Complications; Thrombin Time; Tonsillectomy; Vitamin K

Topics: Blood Coagulation Disorders; Cardiac Surgical Procedures; Diagnosis, Differential; Extracorporeal Circulation; Hemorrhagic Disorders; Humans; Plasma; Postoperative Complications; Protamines; Vitamin K

Topics: Adenoids; Ascorbic Acid; Child; Cyclopropanes; Ethyl Chloride; Ethyl Ethers; Halothane; Humans; Oral Hemorrhage; Postoperative Complications; Preoperative Care; Seasons; Tonsillectomy; Trichloroethylene; Vitamin K

Topics: Dental Prosthesis; Epinephrine; Gingiva; Gingival Hyperplasia; Hemorrhage; Humans; Hyperplasia; Hypertrophy; Illinois; Postoperative Complications; Surgery, Oral; Surgical Procedures, Operative; Tooth Extraction; Vitamin K

Topics: Alcoholism; Anemia; Anemia, Hypochromic; Avitaminosis; Cholestyramine Resin; Common Bile Duct; Diet; Diet Therapy; Diuretics; Folic Acid; Folic Acid Deficiency; Gastrointestinal Hemorrhage; Humans; Hydrochlorothiazide; Ion Exchange Resins; Jaundice; Liver Cirrhosis; Liver Cirrhosis, Biliary; Postoperative Complications; Prothrombin Time; Vitamin B 12; Vitamin B Complex; Vitamin K

Topics: Amino Acids; Anabolic Agents; Asian People; Diet; Diet Therapy; Gastrectomy; Humans; Japan; Kwashiorkor; Postoperative Complications; Steroids; Stomach Ulcer; Vitamin A; Vitamin K; Vitamins