Acute coagulopathy in pregnancy

Pregnancy alters both the fibrinolytic system and coagulation cascade. In addition, pregnancy presents unique triggering mechanisms for DIC. Management of DIC in pregnancy should include removal of the triggering mechanism, blood, and factor replacement. Inherited coagulation defects, while rarely resulting in bleeding diathesis in the pregnant patient, do require monitoring of maternal factor levels. Genetic counseling should be offered to all patients with inheritable coagulation disorders.     

Acquired von Willebrand syndrome in two children with congenital heart defects and abnormal haemodynamics

Acquired von Willebrand syndrome is a rare bleeding disorder associated with other primary diseases such as cardiovascular disorders which can cause severe haemorrhage during surgery or interventional procedures. It should be suspected if there is no history of bleeding and abnormal von Willebrand factor (VWF) values in patients with predisposing disorders. We present two children with congenital heart defects and no personal or family history of bleeding. In these patients we preoperative diagnosed acquired von Willebrand syndrome with coagulation tests including analysis of the VWF multimeric pattern.     

Ischemic colitis revisited: a prospective study identifying hypercoagulability as a risk factor

BACKGROUND: Although causes for ischemic colitis have been identified, many cases are deemed idiopathic. Some reports suggest an association between ischemic colitis and coagulation disorders. Our purpose was to explore the relationship of ischemic colitis and clotting abnormalities. METHODS: Eighteen patients consented to undergo a hypercoagulability evaluation. Tests included protein C, protein S, activated protein C resistance, factor V Leiden, anticardiolipin antibodies, antineutrophil cytoplasmic antibodies, rheumatoid factor, antithrombin III, anti-smooth muscle antibody, lupus anticoagulant panel, and prothrombin 20210G/A mutation (in women undergoing hormone replacement therapy). RESULTS: Five of 18 patients tested positive for coagulation abnormalities, including factor V and activated protein C resistance, protein S deficiency, prothrombin 20210G/A mutation, and anticardiolipin antibody. CONCLUSION: To our knowledge, this is the largest series of patients with ischemic colitis studied for coagulation defects in the United States. The prevalence of clotting disorders in our study (28%) was higher than that in the general population (8.4%). Coagulation disorders should be considered in some cases of ischemic colitis that are thought to be idiopathic.     

Coagulation analysis in transplantation patients

In patients post organ transplantation, the underlying disorder necessitating the transplantation, as well as the transplantation itself, can both mask pre-existing haemostatic abnormalities or lead to them. Since the liver is the main production site for coagulation factors, orthotopic liver transplantation predestinates for acquiring or losing a genetically determined coagulation defect. In coagulation diagnostics, this may lead to a discrepancy between functional plasma tests and molecular biologic findings if these are gathered from nucleated cells of the peripheral blood, as is the standard. Due to the rareness of most defects and the lack of consequences in case of diagnosis of a more common coagulation disorder, no general screening before or after transplantation is required. Underlying diseases leading to liver transplantation as well as the actual transplantation must be considered when interpreting the findings.     

Inherited thrombophilia

Inherited thrombophilia can be defined as a genetically determined predisposition to the development of thromboembolic complications. Since the discovery of activated protein C resistance in 1993, several additional disorders have been described and, at present, it is possible to identify an inherited predisposition in about 60 to 70% of patients with such complications. These inherited prothrombotic risk factors include qualitative or quantitative defects of coagulation factor inhibitors, increased levels or function of coagulation factors, defects of the fibrinolytic system, altered platelet function, and hyperhomocysteinemia. In this review, the main inherited prothrombotic risk factors are analyzed from epidemiological, laboratory, clinical, and therapeutic points of view. Finally, we discuss the synergism between genetic and acquired prothrombotic risk factors in particular conditions such as childhood and pregnancy.     

Caractéristiques évolutives des CIVD au cours de la grossesse,du sepsis,des traumatismes graves,et de lˈinsuffisance hépatique

The course of DIC varies according to the underlying disease in critically ill patients. Changes in coagulation and fibrinolysis have been extensively studied in sepsis. Experimental models and well-conducted clinical studies have provided valuable informations on the dynamic process of DIC. Except in fulminant forms, bleeding complications are unusual. The predominant finding is an imbalance between coagulation activation and reduced fibrinolysis. Numerous arguments favor the concept of an inappropriate fibrinolysis which is a likely determinant of intravascular fibrin deposition, organ failure and death. Available data indicate that this concept may be applied to post-trauma DIC. In obstetric complications, DIC is frequent but, as a general feature, the outcome depends on the successful management of the triggering mechanism rather than on the correction of coagulation disorders. In severe liver failure, multiple coagulopathies make it difficult to identify defects related to DIC. Accelerated coagulation and fibrinolysis have been recognized, but there is no convincing evidence that DIC is a major component of coagulation disorders associated with liver failure and that it plays a leading role in outcome.     

Psychiatric comorbidity in medication overuse headache patients with pre-existing headache type of episodic tension-type headache.

BACKGROUND: Medication overuse headache (MOH) mostly evolves from migraine and episodic tension-type headache (ETTH). Chronic tension-type headache (CTTH) is another headache type that evolves over time from ETTH. It is well known that psychiatric comorbidity is high in MOH patients. AIM: To investigate the frequency of psychiatric comorbidity, and the intensity of depression and anxiety in MOH patients evolving from ETTH and to compare results with CTTH patients and MOH patients evolving from migraine. METHODS: Twenty-eight CTTH (Group C) and 89 MOH patients were included into the study. MOH patients were divided into two groups according to their pre-existing headache types: MOH patients with pre-existing ETTH (Group E, n = 31), and with pre-existing migraine (Group M, n = 58). All patients were interviewed with a psychiatrist and SCID-CV and SCID-II were applied. Beck Anxiety Inventory and Beck Depression Inventory scales were also performed. RESULTS: Eleven patients (39.3%) in Group C, 21 patients (67.7%) in Group E, and 31 patients (53.7%) in Group M were diagnosed to have comorbid psychiatric disorders. The psychiatric comorbidity was found significantly higher in Group E than Group C. In Group E, mood disorders were found significantly higher, but the difference between the two groups with regard to anxiety disorders was insignificant. Mean depression scores were significantly higher in Group E than Group C. The mostly diagnosed type was obsessive-compulsive personality disorder in all the three groups, and was statistically significant in Group M than Group C. CONCLUSION: Psychiatric comorbidity in MOH patients with pre-existing ETTH is common as in those with pre-existing migraine headache and MOH with regard to developing psychiatric disorders should be interpreted as a risk factor in chronic daily headache patients.     

Coagulation abnormalities in critically ill patients

Many critically ill patients develop hemostatic abnormalities, ranging from isolated thrombocytopenia or prolonged global clotting tests to complex defects, such as disseminated intravascular coagulation. There are many causes for a deranged coagulation in critically ill patients and each of these underlying disorders may require specific therapeutic or supportive management. In recent years, new insights into the pathogenesis and clinical management of many coagulation defects in critically ill patients have been accumulated and this knowledge is helpful in determining the optimal diagnostic and therapeutic strategy.     

Adverse reactions to acupuncture

Acupuncture is frequently used as an alternative therapy to drugs in the treatment of pain patients. In this review we discuss adverse reactions to acupuncture by means of case reports and our own clinical experience. Frequent side effects of acupuncture are local pain, autonomic nervous system reactions (including fainting) and small local bleeding or hematomas. There are, however, some case reports of serious adverse reactions. Since 1980, there have been 18 pneumothoraces post acupuncture therapy reported in the literature. Hepatitis due to inadequate hygiene standards has also been reported. Some patients with valvular heart disease have developed endocarditis after acupuncture. Ear acupuncture with permanent needles can cause chondritis or perichondritis. For any acupuncture treatment, a careful case history and exact diagnosis are necessary. In particular, it should be determined whether wound-healing disorders, immunosuppression, coagulation defects, valvular heart disease or pregnancy are present, as all of these constitute relative contraindications to acupuncture. Hygiene standards have to be observed. Bearing these points in mind, acupuncture is a reliable method with few side effects.     

COVID-19 infection and liver injury: Clinical features,biomarkers, potential mechanisms,treatment, and management challenges

It is hypothesized that liver impairment caused by coronavirus disease 2019 (COVID-19) infection might play a central role in severe clinical presentations. Liver injury is closely associated with severe disease and, even with antiviral drugs, have a poor prognosis in COVID-19 patients. In addition to the common hepatobiliary disorders caused by COVID-19, patients with pre-existing liver diseases demand special considerations during the current pandemic. Thus, it is vital that upon clinical presentation, patients with concurrent pre-existing liver disease associated with metabolic dysfunction and COVID-19 be managed properly to prevent liver failure. Careful monitoring and early detection of liver damage through biomarkers after hospitalization for COVID-19 is underscored in all cases, particularly in those with pre-existing metabolic liver injury. The purpose of this study was to determine most recent evidence regarding causality, potential risk factors, and challenges, therapeutic options, and management of COVID-19 infection in vulnerable patients with pre-existing liver injury. This review aims to highlight the current frontier of COVID-19 infection and liver injury and the direction of liver injury in these patients.     

Invasive line placement in critically ill patients: do hemostatic defects matter?

BACKGROUND: Blood components are often given prophylactically before the placement of invasive lines in patients with coagulation defects. Little, however, is known about the epidemiology of defects in these patients. The purpose of this study is to ascertain what proportion of intensive care patients who receive invasive lines have hemostatic defects, what actions are taken by physicians to correct these abnormalities before invasive line insertion, and what the incidence is of bleeding complications after invasive line placement. STUDY DESIGN AND METHODS: Charts were retrospectively reviewed for 490 intensive care patients in whom 938 arterial, pulmonary artery, and central venous lines were placed. RESULTS: At least one defect in hemostasis was documented for 388 patients (41%) before line placement, with 253 (27%) of these patients evidencing severe abnormalities. Seventeen percent of patients had no preprocedure laboratory evaluation. Trauma patients showed the highest numbers of abnormalities in hemostatic testing, but medical patients had more-severe defects. The occurrence of isolated abnormal laboratory values did not predict bleeding, but a score derived from a consideration of multiple defects did. Correction of the abnormalities was attempted in 37 percent of patients with hemostatic defects. Sixteen patients had bleeding complications, but only two had complications that were life-threatening. None of the complications were fatal. CONCLUSION: Invasive lines are used frequently in patients with hemostatic defects, often without any attempt to correct the abnormalities. Nevertheless, rates of hemorrhage are low and appear to be closely related to the level of experience of the physician rather than to defects in hemostasis. These findings suggest that the use of blood components for preprocedure correction of hemostatic defects is not necessary, except in those patients who have the most severe hemostatic abnormalities.     

甲乙型血友病患者合并鼻肿物围术期护理

目的探讨血友病患者行鼻内窥镜手术术前术后护理要点,减少出血,预防并发症的发生。方法总结3名血友病患者(分别为血友病甲型2名及血友病乙型1名),行鼻内窥镜手术围术期的护理体会。结果 3例患者均能如期完成手术,无并发症的发生,顺利出院。结论血友病是一组因遗传性凝血活酶生成障碍引起的出血性疾病,以自发性出血或轻度外伤后出血不止为临床特征,手术往往引起出血不止甚至导致死亡,故一般是手术的禁忌证。术前对于患者及病房做好充分的准备,准确完成凝血因子的预试验,纠正贫血及凝血因子缺乏是非常重要的。术后严密观察出血征象,准确的应用替代疗法,严密观察出血征象,预防DIC及血栓的发生,遵守各项操作规范是患者顺利康复的关键。     

Coagulation biomarkers in critically ill patients

This article discusses coagulation biomarkers in critically ill patients where coagulation abnormalities occur frequently and may have a major impact on the outcome. An adequate explanation for the cause is important, since many underlying disorders may require specific treatment and supportive therapy directed at the underlying condition. Deficiencies in platelets and coagulation factors in bleeding patients or patients at risk for bleeding can be achieved by transfusion of platelet concentrate or plasma products, respectively. Prohemostatic treatment may be beneficial in case of severe bleeding, whereas restoring physiological anticoagulant pathways may be helpful in patients with sepsis and disseminated intravascular coagulation.     

Genomic diagnosis of thrombophilia in women: clinical relevance

The detection of the DNA-sequence of human coagulation factors and inhibitors has introduced the possibility of differentiated mutation analysis in patients with venous thrombosis. Since venous thromboembolism is a multifactorial disease, women are at an increased risk to develop venous thrombosis due to hormonal contraception, during pregnancy and the puerperium. In addition, pregnancy complications like early or late fetal loss, pregnancy-induced hypertensive disorders and very recently recurrent embryo implantation failure have been suspected to be associated with thrombophilia. Therefore, it is of major importance to define inherited thrombophilic disorders, in which genetic diagnosis is of clinical relevance. While most of the genetic defects described so far represent a risk factor for venous thrombosis, only a minority of these defects actually needs DNA analysis to be detected: mutation analysis is clinically relevant, when factor V Leiden mutation is suspected, because relative risks concerning venous thrombosis as well as pregnancy complications clearly differ between homozygote and heterozygote forms of this frequently observed mutation. Similarly detection of the prothrombin mutation G20210A is of clinical relevance, although data for the very rarely observed homozygote variant are not sufficiently available. In contrast, detection of the homozygote variant of the MTHFR-mutation C677T is not useful, since clinical relevance could not be proven in a majority of studies concerning women specific risk situations. Inherited deficiencies of antithrombin, protein C and protein S are rare with high rates of different mutations. Genetic analysis seems only useful in patients with wide intraindividual variations of coagulation inhibitor activities. Genetic analysis concerning the PAI-1 4G/5G polymorphism or the factor XIII Val34Leu polymorphism can not be recommended in women specific risk situations because of insufficient data.     

Venous thromboembolism in patients with COVID-19. A prevalent and a preventable complication of the pandemic

Coronavirus disease 2019 or most commonly known as COVID-19 is a trending global infectious disease which a few months ago was affirmed as a global health emergency or a pandemic by the WHO Emergency Committee. The common symptoms manifested in this pandemic disease are high grade fever, cough, fatigue, shortness of breath and flu like symptom which can evolve into severe respiratory disorders such as pneumonia, acute respiratory distress syndrome (ARDS) and/or end-organ failure. Factors that contribute to the severity or high mortality rate in COVID-19 include old age, comorbidities like hypertension, diabetes, hyperlipidaemia, neutrophilia, and organ and coagulation dysfunction. Disseminated intravascular coagulation and other various coagulopathies including Venous thromboembolism have known to become a major contributing factor to high mortality rate. Venous thromboembolism is a disease which is a combination of deep vein thrombosis and pulmonary embolism. Prophylactic anticoagulation in patients prone to or with a pre-existing history of venous thromboembolism is associated with decreased mortality in severe COVID-19 pneumonia. This review article focuses upon COVID-19 and increased incidence of venous thromboembolism in patients infected by COVID-19 along with the role it has in high mortality rate in COVID-19 patients.     

TRANSFUSION PRACTICE: Thrombin generation in trauma patients

BACKGROUND: Trauma patients are at risk of developing an acute coagulopathy of trauma (ACT) related to tissue injury, shock, and hemodilution. ACT is incompletely understood, but is similar to disseminated intravascular coagulation (DIC) and is associated with poor outcome. STUDY DESIGN AND METHODS: Thrombin generation assays were used to evaluate plasma hemostasis in 42 trauma patients, 25 normal subjects, and 45 patients on warfarin and in laboratory‐prepared factor reduced plasma. RESULTS: Prolonged prothrombin time (PT), more than 18 seconds, or an international normalized ratio of greater than 1.5 was present in 15 trauma patients indicating possible ACT. Native thrombin generation (no activator added, contact activation blocked) showed that Trauma with ACT patients had lag times 68% shorter and peak thrombin generation threefold higher than normal patients indicating the presence of circulating procoagulants capable of initiating coagulation systemically. Trauma patients had lower platelet counts and fibrinogen and Factor (F)II levels putting them at increased risk of bleeding. In laboratory‐prepared isolated factor‐reduced samples and in patients with vitamin K–dependent factor deficiency due to warfarin, thrombin generation decreased in direct proportion to FII levels. In contrast, in diluted plasma and in trauma patients with reduced factor levels, thrombin generation was increased and associated with slower inhibition of thrombin generation (prolonged termination time) and decreased antithrombin levels (43% of normal in Trauma with ACT). CONCLUSIONS: Thrombin generation studies indicate that Trauma with ACT patients show dysregulated hemostasis characterized by excessive non–wound‐related thrombin generation due to a combination of circulating procoagulants capable of activating coagulation systemically and reduced inhibitor levels allowing systemic thrombin generation to continue once started.     

Usefulness of PFA-100® testing in the diagnostic screening of patients with suspected abnormalities of hemostasis: comparison with the bleeding time

BACKGROUND: Global tests of hemostasis that are used to screen patients with clinical suspicion of bleeding disorders should help the physician to identify the phase of the hemostatic system that is abnormal and guide further diagnostic workup. PATIENTS AND METHODS: We compared the performance of Platelet Function Analyzer-100 (PFA-100) closure time (CT) with bleeding time (BT), both of which are screening tests for primary hemostasis, in the diagnostic workup of 128 consecutive patients who were screened for bleeding disorders. The sensitivities of BT and PFA-100 CT for known defects of hemostasis were evaluated; in addition, we calculated their correlation with the levels of severity of the bleeding symptoms, which were recorded using a standardized questionnaire. RESULTS: The sensitivity of PFA-100 testing was 71% for von Willebrand disease (VWD) [with both collagen-adenosine diphosphate (C-ADP) and collagen-epinephrine (C-EPI) cartridges]; 58% (C-EPI) and 8% (C-ADP) for platelet function disorders (PFDs); and the sensitivity of BT was 29% (VWD) and 33% (PFD). C-EPI CT was also prolonged in about 20% of patients with abnormalities of coagulation or fibrinolysis. Only the C-EPI CT was significantly associated with the levels of severity of the patients' bleeding scores. CONCLUSIONS: BT and C-EPI are insufficiently sensitive to be recommended as hemostasis screening tests. The C-ADP cartridge, which is sensitive to VWD only, might prove useful in further diagnostic workup of defects of primary hemostasis. The association of C-EPI CT with the severity of bleeding symptoms as a useful predictor of risk of bleeding in clinical practise should be tested in properly designed studies.     

Significance of a Level-2, "selective, secondary evacuation" hospital during a peripheral town terrorist attack

INTRODUCTION: Mass-casualty incidents (MCIs) can occur outside of major metropolitan areas. In such circumstances, the nearest hospital seldom is a Level-1 Trauma Center. Moreover, emergency medical services (EMS) capabilities in such areas tend to be limited, which may compromise prehospital care and evacuation speed. The objective of this study was to extract lessons learned from the medical response to a terrorist event that occurred in the marketplace of a small Israeli town on 26 October 2005. The lessons pertain to the management of primary and secondary evacuation and the operational practices by the only hospital in the town, which is designated as a Level-2 Trauma Center. METHODS: Data were collected during the event by Home Front Command Medical Department personnel. After the event, formal and informal debriefings were conducted with EMS personnel, the hospitals involved, and the Ministry of Health. The medical response components, interactions (mainly primary triage and secondary distribution), and the principal outcomes were analyzed. The event is described according to Disastrous Incidents Systematic Analysis Through Components, Interactions, Results (DISAST-CIR) methodology. RESULTS: The suicide bomber and four victims died at the scene, and two severely injured patients later died in the hospital. A total of 58 wounded persons were evacuated, including eight severely injured, two moderately injured, and 48 mildly injured. Forty-nine of the wounded arrived to the nearby Hillel Yafe Hospital, including all eight of the severely injured victims, the two moderately injured, and 39 of the mildly injured. Most of the mildly injured victims were evacuated in private cars by bystanders. Five other area hospitals were alerted, three of which primarily received the mildly injured victims. Two distant, Level-1 Trauma Centers also were alerted; each received one severely injured patient from Hillel Yafe Hospital during the secondary distribution process. Emergency medical services personnel were able to treat and evacuate all severely and moderately injured patients within 17 minutes of the explosion. A total of 12 of the 21 ambulances arriving on-scene within the first 20 minutes were staffed by EMS volunteers or off-duty workers. CONCLUSION: When a MCI occurs in a small town that is in the vicinity of a Level-2 Trauma Center, and located a > 40 minute drive from Level-1 Trauma Centers, the Level-2 Trauma Center is a critical component in medical management of the event. All severely and moderately injured patients initially should be evacuated to the Level-2 Trauma Center, and given advanced, hospital-based resuscitation. The patients needing care beyond the capabilities of this facility should be distributed secondarily to Level-1 Trauma Centers. To alleviate the burden placed on the local hospital, some of the mildly injured victims can be evacuated primarily to more distant hospitals. The ability to control the flow of mildly injured patients is limited by the large percentage of them arriving by private cars. The availability of EMS in small towns can be augmented significantly by enrolling off-duty EMS workers and volunteers to the rescue effort. Level-2 hospitals in small towns should be prepared and drilled to operate in a "selective evacuation" mode during MCIs.     

Bleeding and coagulation in the PACU

Understanding normal coagulation processes will allow the critical care nurse to also understand disorders of coagulation. Understanding diagnostic tests used to assess coagulation will also allow the critical care nurse to evaluate disorders of coagulation and to identify patients at risk for bleeding disorders. Both should encourage the critical care nurse to institute appropriate measures designed to minimize and detect further bleeding. Nursing interventions will include maintenance of aseptic technique; minimizing tissue trauma (avoid venipunctures, use of a soft toothbrush); guaiacing stools; monitoring oxygenation and level of consciousness; and monitoring laboratory tests, including hemoglobin and hematocrit, along with laboratory tests of coagulation. Prompt detection and intervention will help minimize the morbidity and mortality associated with bleeding and alterations in coagulation.     

Healthcare utilization and mortality outcomes in patients with pre-existing psychiatric disorders after intensive care unit discharge: A population-based retrospective cohort study

PurposePre-existing psychiatric disorders may lead to negative outcomes following intensive care unit (ICU) discharge. We evaluated the association of pre-existing psychiatric disorders with subsequent healthcare utilization and mortality in patients discharged from ICU.Materials and methodsWe retrospectively studied adult patients admitted to 14 medical-surgical ICUs (January 2014–June 2016) with ICU length stay ≥24 h who survived to hospital discharge. Pre-existing psychiatric disorders were identified using algorithms for diagnostic codes captured ≤5 years before ICU admission. Outcomes were healthcare utilization (emergency department visit, hospital or ICU readmission) and mortality. We used logistic regression models with propensity scores to estimate associations, converted to risk ratios (RR).ResultsWe included 10,598 patients. 37.6% (n = 3982) had a psychiatric history. Patients with pre-existing psychiatric disorders were at higher risk of subsequent emergency department visits (RR 1.49, 95%CI 1.29–1.71), hospital readmission (RR 1.49, 95%CI 1.34–1.66), ICU readmission (RR 2.64, 95%CI 1.55–4.49) one-year post-ICU discharge, compared to patients without pre-existing psychiatric disorders. Patients with pre-existing psychiatric disorders had a higher risk of mortality (RR 1.31, 95%CI 1.00–1.71) six-months post-ICU discharge.ConclusionCritically ill patients with pre-existing psychiatric disorders have an increased risk of healthcare utilization and mortality outcomes following an ICU stay.