A benefit-risk review of systemic haemostatic agents: part 1: in major surgery

Global Current Practice Patterns for the Management of Hyphema

Purpose

Hyphema is a sequela of ocular trauma and can be associated with significant morbidity. Management of this condition is variable and can depend on individual institutional guidelines. We aimed to summarize current practices in hyphema management across ophthalmological institutions worldwide.

Methods

A cross-sectional online survey was conducted across North America, Asia, South America, Africa, Europe, and Australia from August 2020 to January 2021. The survey assessed the existing practices in the management of hyphema at each institution.

Results

For layered hyphema, topical steroids were routinely administered by 34 (of 36 respondents, 94.4%) institutions, of which prednisolone was the preferred choice (n = 32, 88.9%). Topical cycloplegics were used at 34 (94.4%) institutions. No institution reported routine use of antifibrinolytics. Head elevation was the most deployed procedure to promote hyphema reabsorption (n = 31, 86.3%), followed by partial bed rest (n = 21, 58.3%). The majority of institutions (n = 25, 69.4%) did not routinely pursue admission for hyphema patients, although 75.0% of institutions (n = 27) scheduled follow-up visits within 48 hours of presentation. Additionally, few institutions performed routine sickle cell trait testing for patients presenting with hyphema (n = 6, 16.7%). The decision to perform anterior chamber washout varied and was often based on intraocular pressure and the speed of hyphema resolution.

Conclusion

Unanimity of international institutions on hyphema management is lacking. As it stands, many current interventions have unconvincing evidence supporting their use. Evidence-based guidelines would be beneficial in guiding decision-making on hyphema management. Additionally, areas of consensus can be used as foundations for future standard of care investigations.

Abnormal uterine bleeding. Hemostatic therapy: hematologist point of view

Abnormal uterine bleeding (AUB) is a common pathology at the confluence of different specialties, mainly occurring in women of reproductive age. There are two main groups of AUB causes: the structural pathology of the female reproductive system and the functional changes, which include the pathology of the hemostatic system, among other things. Regardless of the severity of manifestations, for the efficacy of the treatment, it is important to establish the certain cause of AUB and to choose the precision therapeutic strategy. However, there are universal therapeutic approaches to provide the hemostatic effect, regardless of the etiology of the process. Fibrinolysis inhibitors, in particular, tranexamic acid, are the basis of this approach.

Tranexamic acid in head and neck procedures: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

We conducted a meta-analysis of all randomized controlled trials (RCTs) that examined the benefits of tranexamic acid (TXA) among cancer patients undergoing head and neck (H&N) procedures.

METHODS

We screened five databases from inception until 20 June 2021 and evaluated the risk of bias of the eligible studies. We pooled continuous outcomes using the weighted mean difference (WMD) with 95% confidence interval (CI).

RESULTS

Five studies, comprising seven RCTs, met the inclusion criteria. This meta-analysis included a total of 540 patients; 265 and 275 patients were assigned to the TXA and control group, respectively. Overall, the included RCTs revealed a low risk of bias. The volume of postoperative bleeding was significantly lower in favor of the TXA group compared with the control group (n = 7 RCTs, WMD = - 51.33 ml, 95% CI [- 101.47 to - 1.2], p = 0.04). However, no significant difference was found between both groups regarding the volume of intraoperative bleeding (n = 6 RCTs, WMD = - 3.48 ml, 95% CI [- 17.11 to 10.15], p = 0.62), postoperative hemoglobin (n = 3 RCTs, WMD = 0.42 mg/dl, 95% CI [- 0.27 to 1.11], p = 0.23), duration of drainage tube removal (n = 4 RCTs, MD = - 0.41 days, 95% CI [- 1.14 to 0.32], p = 0.27), and operation time (n = 6 RCTs, WMD = 1.59 min, 95% CI [- 10.09 to 13.27], p = 0.79). TXA was safe and did not culminate in thromboembolic events or major coagulation derangements.

CONCLUSION

TXA administration is safe and significantly reduces the volume of postoperative bleeding. However, no difference is identified between TXA and control groups regarding the volume of intraoperative bleeding, postoperative hemoglobin level, duration of drainage tube removal, and operation time.

Impact of Contraception on Uterine Fibroids

Background and Objectives: Uterine fibroids develop in 25–40% of women of childbearing age; however, there are discrepancies resulting from population and socioeconomic differences. The pathogenesis of fibroids is not clear. The aim of the study was to assess the potential connection between the use of oral contraceptives and the occurrence of uterine fibroids in women of childbearing age. Materials and Methods: In this prospective, survey, case–control study, data were collected from Caucasian female patients (mean age = 30) using a questionnaire concerning the onset, duration and form of hormonal contraception, and medical and obstetrical history. The questionnaires were handed personally to hospitalized patients as well as distributed through Google forms on social media. Results: In a study group (n = 140) of patients using hormonal contraception, 37.8% of them were diagnosed with uterine fibroids, whereas among the patients not using hormonal contraception (n = 206), uterine fibroids were diagnosed in 59.6% of the patients. The most common hormonal contraception was two-component hormonal tablets used by 93.3% of the patients. Taking contraceptives was a uterine fibroids protective factor (OR = 0.4, p = 0.007). In the study group, 5.5% of the patients were pregnant and 60.42% were diagnosed with uterine fibroids (OR = 4.4, p < 0.000001). Conclusion: Contraception was found to be a protective factor for uterine fibroids among the women surveyed. The presented data confirm the theory about the hormonal dependence of uterine fibroids.

Beneficial effects of early hemostasis on spinal cord injury in the rat

STUDY DESIGN

Experimental study.

OBJECTIVES

To investigate the effect of early hemostasis on spinal cord injury (SCI).

SETTING

Fourth Military Medical University, Xi'an, China.

METHODS

Sprague Dawley rats were used. Hematoxylin and eosin (HE) staining was performed to observe hemorrhage at different time points (2, 6, 12, 24 and 48 h) after SCI to determine the time window of hemostatic drug administration (n=3 per time point). Three different concentrations of Etamsylate (0.025, 0.05 and 0.1 g kg-1) were administered immediately and 5 and 10 h after SCI to evaluate the effective dosage (n=6 per group). Another 82 rats were then randomly divided into two groups, Etamsylate group (0.1 g kg-1, n=41) and glucose control group (n=41). Nissl staining was performed to observe neurons at 10 days post injury. Immunohistochemistry, western blot and quantitative real-time PCR were performed to detect tissue necrosis at 7 d.p.i., the activation of astrocytes and microglia/macrophages and lesion cavity at 10 d.p.i. Basso-Beattie-Bresnahan scoring and rump height index assay were used to examine locomotion recovery.

RESULTS

Early hemostasis reduced the lesion area and tissue necrosis, enhanced neuronal survival, alleviated the activation of microglia/macrophages and astrocytes and facilitated functional recovery after spinal cord contusion in rats. Early hemostasis decreased hemorrhage area and lesion area after spinal cord transection in rats.

CONCLUSION

The present study demonstrated that early hemostasis has beneficial effects on SCI in the rat. It has the potential to be translated into clinical practice.

Venous thromboembolism and mortality associated with tranexamic acid use during total hip and knee arthroplasty

TKA and THA are associated with blood transfusion and risk for postoperative venothromboembolism (VTE). Reports show that tranexamic acid (TA) may be safe to use in high-risk orthopedic patients, but further data are needed to substantiate its use. All patients who underwent primary or revision TKA or THA in a five year period were retrospectively identified. In 13,262 elective TKA or THA procedures, neither the odds of VTE (OR=0.98; 95% CI 0.67-1.45; P=0.939) or adjusted odds of death (OR=0.26; 95% CI 0.04-1.80; P=0.171) were significant with TA administration. The major findings of this large, single center, retrospective cohort study show the odds of postoperative VTE and 30-day mortality were unchanged with TA administration.

Non-contraceptive benefits of oral hormonal contraceptives

It is becoming evident that oral hormonal contraceptives-besides being well established contraceptives-seem to become important medications for many functional or organic disturbances. So far, clinical effectiveness has been shown for treatment as well as prevention of menstrual bleeding disorders and menstrual-related pain symptoms. Also this is true for premenstrual syndrome (PMS) and premenstrual disphoric disorder (PMDD). Particular oral contraceptives (OCs) containing anti-androgenic progestogens were shown to be effective medications for treatment of androgenisation symptoms (seborrhea, acne, hirsutism, alopecia). Through perfect suppression of the hypothalamic-pituitary-ovarian axis OCs have proven to be effective in elimination of persistent follicular cysts. Endometriosis/adenomyosis related pain symptoms are well handled similar to other drugs like Gonadotropine Releasing Hormone agonists but are less expensive, with less side effects, and possibility to be used for longer periods of time. This is also true for myoma. Pelvic inflammatory disease, rheumatoid arthritis, menstrual migraine, and onset of multiple sclerosis are prevented or delayed. Bone density is preserved and asthma symptoms improved. Endometrial hyperplasia and benign breast disease can be controlled. There is definitely a significant impact on risk reduction regarding endometrial, ovarian, and colon cancers. In conclusion, it needs to be recognized that oral combined hormonal contraceptives (estrogen/ progestogen combination) are - besides being reliable forms of contraception - are cost-effective medications for many medical disorders in women. Therefore, these contraceptives drugs are important for female and global health and should be used in clinical practice.

Reducing Heavy Menstrual Bleeding: Safety and Efficacy of Tranexamic Acid

Menorrhagia or Heavy Menstrual Bleeding (HMB) remains a public health challenge among women in the reproductive age group. Anti-fibrinolytics such as tranexamic acid and epsilon aminocaproic acid, play an important role in the medical management of HMB, as HMB is associated with an increase in local fibrinolysis. Lysteda is a novel oral formulation of tranexamic acid which has recently been approved by the US FDA for treatment of HMB. Efficacy of tranexamic acid in the general gynecologic population as well as in women with bleeding disorders is discussed in this review. Safety and adverse effect profile is also addressed for both these populations.

Disseminated Intravascular Coagulation During Resection of a Meningioma: Case Report

BACKGROUND AND IMPORTANCE:

Disseminated intravascular coagulation is a relatively common complication in patients with trauma, sepsis, obstetric calamities, and certain malignancies. We report a rare case of DIC after embolization and surgery for a large meningioma. We also review the literature on coagulopathy during brain tumor surgery as well as the diagnosis and treatment of this complication.

CLINICAL PRESENTATION:

A 62-year-old woman presented with a 3-week history of aphasia, difficulty with handwriting, personality change, and right-sided weakness. Magnetic resonance imaging demonstrated a 6.3 × 5.4-cm multilobe and avidly enhancing mass within the left frontal region. The patient underwent preoperative transcatheter Onyx embolization of the tumor, followed immediately by craniotomy for resection of the tumor. Surgery was complicated by coagulopathy leading to substantial blood loss. The diagnosis of disseminated intravascular coagulation was established by intraoperative thromboelastography, after which the patient was treated with replacement therapy, Amicar, and modest hypotension. One year after surgery, the patient had fully recovered and had no focal neurological deficit.

CONCLUSION:

This case report adds to the few reported cases of disseminated intravascular coagulation as a complication of brain tumor surgery. This patient's successful outcome may be attributed to timely recognition of the condition and effective, prompt treatment.

Tranexamic Acid: A Novel Oral Formulation for the Treatment of Heavy Menstrual Bleeding

Tranexamic acid, a synthetic lysine derivative, is an antifibrinolytic drug that prevents the breakdown of fibrin by competitively blocking binding sites of plasminogen. Tranexamic acid is often considered a first-line treatment for the management of heavy menstrual bleeding (HMB). A new oral formulation of tranexamic acid provides a nonhormonal HMB therapy that is safe, effective and well tolerated; is administered only during menstruation; addresses the excessive fibrinolysis implicated in many cases of HMB; and improves women's health-related quality of life by reducing limitations on physical, social and leisure activities. This article provides a summary of the clinical development, therapeutic efficacy and tolerability profile of this novel formulation of tranexamic acid for the treatment of HMB.

Acquired hemophilia as the cause of life-threatening hemorrhage in a 94-year-old man: a case report

Introduction

Acquired factor VIII deficiency is a rare entity that can lead to severe and life-threatening bleeding. We describe a case of severe bleeding from the tongue secondary to acquired hemophilia and discuss treatment options, including aminocaproic acid and recombinant factor VIII, which have not been widely reported in the literature for the management of such patients.

Case presentation

A 94-year-old Caucasian man presented to our institution with diffuse bruising and extensive bleeding from the tongue secondary to mechanical trauma. He had no prior history of bleeding and his medical history was unremarkable except for dementia and hypertension. Coagulation studies revealed a prolonged activated partial thromboplastin time and a mixing study was consistent with the presence of an inhibitor. Quantitative assays revealed a reduced level of factor VIII activity (1%) and the presence of a factor VIII inhibitor, measured at seven Bethesda units, in the serum. Oral prednisone therapy (60mg/day) was given. He also received intravenous aminocaproic acid and human concentrate of factor VIII (Humate-P) and topical anti-thrombolytic agents (100 units of topical thrombin cream). His hospital course was prolonged because of persistent bleeding and the development of profuse melena. He required eight units of packed red blood cells for transfusion. Hospitalization was also complicated by bradycardia of unclear etiology, which started after infusion of aminocaproic acid. His activated partial thromboplastin time gradually normalized. He was discharged to a rehabilitation facility three weeks later with improving symptoms, stable hematocrit and resolving bruises.

Conclusions

Clinicians should suspect a diagnosis of acquired hemophilia in older patients with unexplained persistent and profound bleeding from uncommon soft tissues, including the tongue. Use of factor VIII (Humate-P) and aminocaproic acid can be useful in this coagulopathy but clinicians should be aware of possible life-threatening side effects in older patients, including bradycardia.

Interstitial plasmin activity with epsilon aminocaproic acid: temporal and regional heterogeneity

BACKGROUND

Epsilon aminocaproic acid (EACA) is used in cardiac surgery to modulate plasmin activity (PLact). The present study developed a fluorogenic-microdialysis system to measure in vivo region specific temporal changes in PLact after EACA administration.

METHODS

Pigs (25 to 35 kg) received EACA (75 mg/kg, n = 7) or saline in which microdialysis probes were placed in the liver, myocardium, kidney, and quadricep muscle. The microdialysate contained a plasmin-specific fluorogenic peptide and fluorescence emission, which directly reflected PLact, determined at baseline, 30, 60, 90, and 120 minutes after EACA/vehicle infusion.

RESULTS

Epsilon aminocaproic acid caused significant decreases in liver and quadricep PLact at 60, 90, 120 minutes, and at 30, 60, and 120 minutes, respectively (p < 0.05). In contrast, EACA induced significant biphasic changes in heart and kidney PLact profiles with initial increases followed by decreases at 90 and 120 minutes (p < 0.05). The peak EACA interstitial concentrations for all compartments occurred at 30 minutes after infusion, and were fivefold higher in the renal compartment and fourfold higher in the myocardium, when compared with the liver or muscle (p < 0.05).

CONCLUSIONS

Using a large animal model and in vivo microdialysis measurements of plasmin activity, the unique findings from this study were twofold. First, EACA induced temporally distinct plasmin activity profiles within the plasma and interstitial compartments. Second, EACA caused region-specific changes in plasmin activity profiles. These temporal and regional heterogeneic effects of EACA may have important therapeutic considerations when managing fibrinolysis in the perioperative period.

[Coagulation management in the treatment of multiple trauma]

In recent years a new understanding of trauma-associated hemorrhaging and trauma-induced coagulopathy has been achieved. This coagulopathy is multifactorial with the predominant mechanisms being tissue trauma, shock and hypoperfusion which can lead to hyperfibrinolysis by activation of the endothelium. Routinely tested coagulation parameters, such as prothrombin time and partial thromboplastin time, are frequently employed for decision making but remain problematic as they do not give any information on clot stability, lysis or platelet function. Thrombelastometry seems to be a useful alternative. A pro-active anticipatory approach is required for a successful outcome to be achieved as rescue correction is more difficult than prevention. While the pathophysiological conception of causal relationship of the mentioned therapeutic options is conclusive, an evidence-based validation by randomized controlled studies is mostly lacking. The emergency and anesthesiological concept of damage control resuscitation consists of limiting volume therapy with crystalloids and colloids to reach a mean arterial pressure > or =65 mmHg (higher for head injuries), active (re-)warming management, the prevention of a pH< or =7.2 and a base excess (BE) < or =-6 mmol/l. The early and sufficient application of hemostatic drugs is essential. Because erythrocytes play a substantial role in the coagulation process, hemoglobin (Hb) values of around 6. 2 mmol/l (10 g/dl) and/or a hematocrit of 30% should be strived for when massive non-arrested hemorrhaging occurs. After severe multiple trauma a fibrinogen deficit develops and must be adequately compensated. If coagulation therapy is carried out using fresh frozen plasma sufficient quantities (20-30 ml/kgBW) must be administered to correspondingly raise the coagulation factors. Prothrombin complex concentrates can be helpful to optimize thrombin generation during severe hemorrhaging. Because hyperfibrinolysis occurs more often than previously assumed during severe trauma, an anti-fibrinolytic therapy should be used especially for patients with an instable circulation. The platelet count should not go below 100,000/microl when hemorrhaging occurs after multiple trauma. For thrombocytopathic patients with diffuse bleeding desmopressin (DDAVP) is a therapeutic option and the "off label" use of recombinant activated factor VIIa (rFVIIa) remains an option for individual situations with stringent indications and when the above named measures to optimize the coagulation situation have been taken.

Temporally and regionally disparate differences in plasmin activity by tranexamic acid

BACKGROUND

A major complication associated with cardiac surgery is excessive and prolonged bleeding in the perioperative period. Improving coagulation by inhibiting fibrinolysis, primarily through inhibition of plasmin activity (PLact) with antifibrinolytics such as tranexamic acid (TXA), has been a pharmacological mainstay in cardiac surgical patients. Despite its almost ubiquitous use, the temporal and regional modulation of PLact profiles by TXA remains unexplored. Accordingly, we developed a fluorogenic-microdialysis system to measure in vivo dynamic changes in PLact after TXA administration in a large animal model.

METHODS

Pigs (25-35 kg) were randomly assigned to receive TXA (30 mg/kg, diluted into 50 mL normal saline; n = 9) or vehicle (50 mL normal saline; n = 7). Microdialysis probes were placed in the liver, myocardium, kidney, and quadriceps muscle compartments. The microdialysate infusion contained a validated plasmin-specific fluorogenic peptide. The fluorescence emission (standard fluorogenic units [SFU]) of the interstitial fluid collected from the microdialysis probes, which directly reflects PLact, was determined at steady-state baseline and 30, 60, 90, and 120 min after TXA/vehicle infusion. Plasma PLact was determined at the same time points using the same fluorogenic substrate approach.

RESULTS

TXA reduced plasma PLact at 30 min after infusion by >110 SFU compared with vehicle values (P < 0.05). Specifically, there was a decrease in liver PLact at 90 and 120 min after TXA infusion of >150 SFU (P < 0.05) and 175 SFU (P < 0.05), respectively. The decrease in liver PLact occurred 60 min after the maximal decrease in plasma PLact. In contrast, kidney, heart, and quadriceps PLact transiently increased followed by an overall decrease at 120 min.

CONCLUSIONS

Using a large animal model and in vivo microdialysis measurements of PLact, the unique findings from this study were 2-fold. First, TXA induced temporally distinct PLact profiles within the plasma and selected interstitial compartments. Second, TXA caused region-specific changes in PLact profiles. These temporal and regional differences in the effects of TXA may have important therapeutic considerations when managing fibrinolysis in the perioperative period.

Challenges of major obstetric haemorrhage

Every minute of every day, a woman dies in pregnancy or childbirth. The biggest killer is obstetric haemorrhage, the successful treatment of which is a challenge for both the developed and developing worlds. The presence of an attendant at every birth and access to emergency obstetric care are key to reducing maternal morbidity and mortality in the developing world while resource-rich countries have a rising caesarean section rate with its consequential effect on the incidence of abnormal placentation and its link with peripartum hysterectomy. Management of obstetric haemorrhage involves early recognition, assessment and resuscitation. Various methods are available to try to stop the bleeding - from pharmacological methods to aid uterine contraction (e.g., oxytocinon, ergometrine and prostaglandins) to surgical methods to stem the bleeding (e.g., balloon tamponade, compression sutures or arterial ligation). Interventional radiology can be used if placenta accreta is suspected. Cell salvage has been introduced into obstetrics relatively recently in an attempt to reduce allogeneic transfusion.