Injection of fibrin tissue adhesive versus laser photocoagulation in the treatment of high-risk bleeding peptic ulcers: a controlled randomized study.
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Female↗
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Results for “Bleeding risk”
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Hemodialysis for patients bleeding or at risk for bleeding, can be simple, safe and efficient.
AIM: Hemodialysis for patients bleeding or at risk for bleeding requires special modalities of treatment that are difficult to perform without potential side effects. A simple, safe and adequate method may be applied. METHODS: A modified way of extracorporeal circuit preparation, which focuses on minimizing the blood-air interface and negligible saline flushing of 50 ml/h, is applied for a maximum of 3-hour session with routine (not one-to-one) nursing attendance. Data from 16,954 sessions performed with patients bleeding or at risk for bleeding (15,730 retrospectively and 1,224 prospectively collected) were analyzed. RESULTS: Cumulative failure of treatment, as defined by clotting of the extracorporeal circuit requiring termination of the procedure or replacement of the clotted part, was not more than 5% as expected for anticoagulation-free hemodialysis. For the prospectively recorded sessions, blood flow was 234 +/- 30 ml/min with less than 250 ml/min in 42.4% of the sessions. Native blood access was used in 426 (34.8%), double-lumen catheter in 798 (65.2%), 42 were isolated ultrafiltration sessions and 64 blood, 21 plasma, 9 platelet units were transfused. Post/pre urea ratio was 0.50 +/- 0.12. Logistic regression showed that among the following: duration of the session, type of dialysis, ultrafiltration rate, hematocrit, number of platelets, serum total protein, transfusions, blood flow and type of access, only blood flow significantly affected failure incidence (coefficient B = -0.041, exp(B) = 0.96, p = 0.04). No complications due to treatment were noted. CONCLUSION: In patients with active, or at risk for, bleeding, hemodialysis without systemic anticoagulation can be adequately and safely performed almost as a routine session.
Adolescent↗
Risk of bleeding and restenosis among chronic kidney disease patients undergoing percutaneous coronary intervention.
BACKGROUND: Bleeding risk is increased in renal failure due to impaired platelet adhesiveness. Patients who undergo percutaneous coronary intervention (PCI) are given multiple antiplatelet agents that increase that risk. We retrospectively tested the hypothesis that chronic kidney disease (CKD) patients who undergo PCI are at higher risk of bleeding and restenosis (due to chronic inflammation) compared to patients with normal renal function. METHODS: Patients who had PCI for non-ST elevation myocardial infarction or unstable angina between July 2001 and June 2003 (1,184 patients) were included in the study. All the patients were given periprocedural clopidogrel, aspirin and glycoprotein IIb/IIIa inhibitor if indicated, and then continued on clopidogrel and aspirin daily for 12 months. The patients were classified into 5 groups according to the CKD stage and followed-up for 12 months for development of major or minor bleeding, restenosis, length of hospital stay and survival. RESULTS: The incidence of major bleeding within the first month (3.4% in normal kidney function patients (Gp 1), 4.8% for CKD Stages 1 and 2 patients (Gp2), 5.2% for CKD Stage 3 patients (Gp3), 6.1% for CKD Stage 4 patients (Gp4) and 9.3% for CKD Stage 5 patients (Gp5), p = 0.001) and for minor bleeding (5.7% in Gp1, 6.5% for Gp2, 7.4% for Gp3, 9.2% for Gp4 and 11.3% for Gp5, p = 0.001) and the incidence of restenosis at one month (4.6% in Gp1, 5.3% for Gp2, 6.8% for Gp3, 7.3% for Gp4 and 9.6% for Gp5, p = 0.001) and 6 months (11.2% in Gp1, 13.5% for Gp2, 15.7% for Gp3, 16.4% for Gp4 and 19.7% for Gp5, p = 0.001) were higher with worsening CKD. Survival at one year was worse with worsening of the kidney function. CONCLUSION: Worsening of CKD is associated with progressively increased risk of minor and major bleeding, restenosis and death during and after PCI.
Analysis of Variance↗
Routine coagulation screening in children undergoing gastrointestinal endoscopy does not predict those at risk of bleeding.
BACKGROUND AND STUDY AIMS: Routine coagulation screening prior to gastrointestinal endoscopy is performed in many centres in the UK, despite the lack of any evidence to support the practice. The aim of this study was to assess the benefits of routine pre-endoscopy coagulation screening in children and to assess how widespread this practice is in the UK. PATIENTS AND METHODS: We performed a retrospective analysis of the case notes of 250 consecutive patients who had undergone routine coagulation screening prior to endoscopy and biopsy, in accordance with our unit's protocol, looking for evidence of abnormal results or episodes of bleeding. We also performed a telephone survey of the protocols for coagulation screening at other paediatric units in the UK which are known to perform gastrointestinal endoscopy on a routine basis. RESULTS: According to our hospital's laboratory reference ranges, 16.8 % of the children who underwent endoscopy and biopsy had abnormal clotting. This was neither clinically significant nor associated with an increased bleeding risk in any patient. Of the 23 UK paediatric gastroenterology centres surveyed, including our own, five (21.7 %) perform routine coagulation screening before endoscopy. CONCLUSIONS: This study suggests that, although it is a relatively common practice, routine coagulation screening is not indicated in children who are undergoing gastrointestinal endoscopy and biopsy, and that it does not predict those at risk of significant bleeding. We would therefore suggest that if pre-endoscopy screening is to be performed, it should be reserved for those who are potentially at high risk of bleeding.
Blood Coagulation Disorders↗
Comparison of bleeding in patients with nonvalvular atrial fibrillation treated with ximelagatran or warfarin: assessment of incidence, case-fatality rate, time course and sites of bleeding, and risk factors for bleeding.
BACKGROUND: Ximelagatran is a novel direct thrombin inhibitor that can be administered as a fixed oral dose, without the need for anticoagulant monitoring. METHODS: We undertook a pooled analysis of 7329 patients with nonvalvular atrial fibrillation from the Stroke Prevention Using Oral Thrombin Inhibitor in Atrial Fibrillation III and V trials to compare bleeding outcomes in patients who received ximelagatran, 36 mg twice daily, or warfarin sodium (target international normalized ratio, 2.0-3.0). We determined annual risk of bleeding (any, major), case-fatality rate, time course and anatomic sites of major bleeding, and risk factors for major bleeding with ximelagatran and warfarin treatment. RESULTS: Annual incidence of any bleeding was 31.75% with ximelagatran and 38.82% with warfarin (relative risk reduction, 18.2%; 95% confidence interval [CI], 13.0-23.1; P<.001). Annual incidence of major bleeding was 2.01% with ximelagatran and 2.68% with warfarin (relative risk reduction, 25.1%; 95% CI, 3.2-42.1; P = .03). Case-fatality rate of bleeding was comparable in ximelagatran- and warfarin-treated patients (8.16% vs 8.09%; P = .98). Cumulative incidence of major bleeding was higher with warfarin than ximelagatran after 24 months of treatment (4.7% vs 3.7%; P = .04). Anatomic sites of bleeding were comparable with both treatments. Risk factors for bleeding with ximelagatran were as follows (hazard ratios and 95% CIs in parentheses): diabetes mellitus (1.81; 1.19-2.77; P = .006), previous stroke or transient ischemic attack (1.78; 1.16-2.73; P = .008), age 75 years or greater (1.70; 1.33-2.18; P<.001), and aspirin use (1.68; 1.08-2.59; P = .02). Risk factors for bleeding in warfarin-treated patients were previous liver disease (4.88; 1.55-15.39; P = .007); aspirin use (2.41; 1.69-3.43; P<.001); and age 75 years or greater (1.26; 1.03-1.52; P = .02). CONCLUSIONS: Treatment with ximelagatran, 36 mg twice daily, is associated with a lower risk of bleeding than warfarin in patients with nonvalvular atrial fibrillation. Aspirin use and increasing age were associated with an increased risk of bleeding in ximelagatran- and warfarin-treated patients.
Adolescent↗
The clinical usefulness of the preoperative bleeding time.
OBJECTIVES: To determine the clinical utilization of the Simplate bleeding time test as a preoperative screen, to examine the clinical utilization of the bleeding time test by multiple surgical services, and to correlate the indicators of bleeding risk (bleeding history, thrombocytopenia, prolonged prothrombin time/activated partial thromboplastin time, increased creatinine, and medications known to interfere with platelet function) with the bleeding time and the occurrence of clinically significant perioperative bleeding. DESIGN: Retrospective data analysis. SETTING: A large tertiary-care hospital. PATIENTS: One hundred sixty-seven consecutive surgical patients tested for preoperative bleeding time. MAIN OUTCOME MEASURES: The occurrence of clinically significant perioperative bleeding and the positive and negative predictive value of the preoperative screening bleeding time test. RESULTS: Patients with a positive bleeding history were more likely to have an abnormal bleeding time (P = .04), but there was no statistically significant association between patients with an abnormal bleeding time and the other indicators of bleeding risk examined or the occurrence of clinically significant perioperative bleeding. The positive predictive value of the preoperative bleeding time was 5%, and the negative predictive value was 95%. CONCLUSIONS: Screening for preoperative bleeding time is not a reliable test for assessing the risk of clinically significant perioperative bleeding and should not be used for this purpose.
Bleeding Time↗
Natural history. Clinical-haemodynamic correlations. Prediction of the risk of bleeding.
Promoting the development of oesophageal varices and ascites, portal hypertension dominates the clinical course of cirrhosis. Varices appear in patients with portal pressure gradient above 10 mmHg and enlarge in 10-20% within 1-2 years of their detection. Bleeding occurs in patients with portal pressure gradient above 12 mmHg when the wall tension causes the rupture of varices, with an incidence of about 10% per year. Indicators of bleeding risk are portal pressure gradient, variceal pressure, large varices and liver dysfunction. Mortality per bleeding episode is 30-50%. Among survivors 60% will rebleed and 30% will die in the following year. The risk of rebleeding decreases in patients with spontaneous or treatment induced reduction of portal pressure gradient or variceal pressure. Ascites develops in almost all patients along the course of the disease. Median survival after its appearance is less than 2 years. Less than 5% of cirrhotic patients die without ascites or without a previous bleeding. Thus portal hypertension is a major determinant of survival in cirrhosis.
Acute Disease↗
Inherited factor VII deficiency and surgery: clinical data are the best criteria to predict the risk of bleeding.
Inherited factor VII (FVII) deficiency is a rare autosomal disorder characterized by a weak relationship between FVII activity (FVII:C) and operative bleeding risk. We report a retrospective study of 17 patients with a FVII:C below 0.1 IU/ml, in whom surgery was performed without any replacement therapy. Clinical and biological data were analysed to establish predictive criteria for bleeding tendency. We found that systematic preoperative replacement therapy may not be necessary for 'minor' surgical procedures, for patients suffering from inherited FVII deficiency, unless the clinical history includes severe haemorrhagic symptoms such as haemarthrosis, severe haematomas (even of soft tissue) or abundant epistaxis.
Adolescent↗
Eptifibatide: a review of its use in patients with acute coronary syndromes and/or undergoing percutaneous coronary intervention.
UNLABELLED: Eptifibatide, a cyclic peptide, is a highly specific, intravenously administered glycoprotein (GP) IIb/IIIa receptor antagonist. By preventing fibrinogen binding to the GP IIb/IIIa receptor, eptifibatide inhibits platelet aggregation and prevents thrombus formation. Clinically, the drug is used as an adjunct to heparin and aspirin. The PURSUIT trial, conducted in >10,000 patients with unstable angina or non-Q-wave myocardial infarction (MI), showed that eptifibatide (180 microg/kg bolus then 2 microg/kg/min infusion for < or =72 hours) reduces the 30-day risk of death or nonfatal MI, with this benefit apparent at 96 hours. The absolute reduction in this end-point of 1.5% persisted at 6 months. The drug is effective in patients undergoing percutaneous coronary intervention (PCI), and, as shown in the North American subgroup, in patients in whom medical management is appropriate. Eptifibatide is also beneficial in patients undergoing PCI, whether or not they have unstable angina or non-Q-wave MI. In a dosage of 135 microg/kg then 0.5 microg/kg/min for 24 hours, eptifibatide reduced the 30-day risk of a combined end-point (death, nonfatal MI and urgent or emergency coronary interventions) by 2.5% (absolute reduction) in patients undergoing PCI in the IMPACT-II trial, when measured by per-protocol (patients treated), but not intent-to-treat, analysis. The drug also decreased the incidence of abrupt vessel closure and ischaemic cardiovascular complications in the first 24 hours (the period of greatest risk). Bleeding episodes are the most common adverse event associated with eptifibatide therapy. Although the incidence of major bleeding is increased with eptifibatide, most bleeding episodes are minor and occur at the vascular access site. The drug is not associated with an excess of intracranial bleeds, stroke or thrombocytopenia, does not appear to increase bleeding risk in patients undergoing coronary artery bypass graft (CABG), and does not cause antibody formation. Limited data suggest that eptifibatide may improve coronary flow when combined with alteplase in patients with acute Q-wave MI, but the possibility of increased bleeding with eptifibatide plus thrombolytics should be borne in mind. CONCLUSIONS: Intravenous eptifibatide, when combined with aspirin and heparin, reduces the 30-day risk of ischaemic events in patients with unstable angina and non-Q-wave MI and decreases ischaemic cardiovascular complications at the time of greatest risk in patients undergoing PCI. With its acceptable tolerability profile eptifibatide is a suitable option as a short term adjunct in these clinical settings. Whether eptifibatide in combination with fibrolysis may improve outcome in patients with acute Q-wave MI has yet to be determined.
Angina, Unstable↗
Does the measurement of portal flow velocity have any value in the identification of patients with cirrhosis at risk of digestive bleeding?
Upper gastrointestinal bleeding is a leading cause of death in patients with liver cirrhosis. In most cases haemorrhage originates from oesophageal varices or from congestive gastropathy, and the evaluation of the bleeding risk is based on oesophagogastroduodenoscopic data. The aim of this prospective study was to determine whether the measurement of portal flow velocity by Duplex-Doppler, compared with endoscopic data, can help in detecting patients with cirrhosis at risk of bleeding. One hundred and seventy-three patients underwent endoscopy to ascertain the size of the varices and the severity of congestive gastropathy. For each patient maximal portal flow velocity measurements were obtained. No difference in portal flow velocity was observed between patients with or without oesophageal varices or congestive gastropathy. During a 2-year observation period, 27 patients (15.6%) had at least one episode of acute digestive bleeding. Stepwise multiple logistic regression analysis demonstrated a correlation between oesophageal varices and congestive gastropathy endoscopic grading and the incidence of bleeding; only the former was entered into the final regression equation (p < 0.001). No relationship between the max portal flow velocity value and incidence of bleeding was found. This study shows that portal flow velocity is unrelated to the degree of the endoscopic abnormalities in patients with liver cirrhosis and that it has no value in the identification of patients with cirrhosis at risk of upper gastrointestinal bleeding.
Adult↗
Prospective evaluation of an index for predicting the risk of major bleeding in outpatients treated with warfarin.
PURPOSE: To evaluate the accuracy and clinical utility of the Outpatient Bleeding Risk Index for estimating the probability of major bleeding in outpatients treated with warfarin. The index was previously derived in a retrospective cohort of 556 patients from a different hospital (derivation cohort). SUBJECTS AND METHODS: We enrolled 264 outpatients starting warfarin (validation cohort) to validate the index prospectively. All patients were identified upon hospital discharge, and physician estimates of the probability of major bleeding were obtained before discharge in the validation cohort. RESULTS: Major bleeding occurred in 87 of 820 outpatients (6.5%/yr). The index included four independent risk factors for major bleeding: age 65 years or greater; history of gastrointestinal bleeding; history of stroke; and one or more of four specific comorbid conditions. In the validation cohort, the index predicted major bleeding: the cumulative incidence at 48 months was 3% in 80 low-risk patients, 12% in 166 intermediate-risk patients, and 53% in 18 high-risk patients (c index, 0.78). The index performed better than physicians, who estimated the probability of major bleeding no better than expected by chance. Of the 18 episodes of major bleeding that occurred in high-risk patients, 17 were potentially preventable. CONCLUSIONS: The Outpatient Bleeding Risk Index prospectively classified patients according to risk of major bleeding and performed better than physicians. Major bleeding may be preventable in many high-risk patients by avoidance of over-anticoagulation and nonsteroidal anti-inflammatory agents.
Aged↗
[Hemostatic requirements for the performance of regional anesthesia. Workshop on hemostatic problems in regional anesthesia].
There is uncertainty as to which preoperative examinations are necessary before performing regional anesthesia. Therefore an interdisciplinary consensus conference was established to obtain recommendations on some of the open questions related to this topic. Preoperative laboratory examinations are not necessary prior to peripheral nerve blocks near large vessels if these are easy to compress. In patients on anticoagulant therapy direct puncture of the vessel should be avoided. Prior to spinal or epidural anesthesia, no preoperative laboratory examinations are necessary if no anamnestic or clinical evidence of coagulation disorders exists. Otherwise the following examinations are useful: clotting time, prothrombin time, partial thromboplastin time (PTT), and thrombocyte count. Low-dose heparin prophylaxis is no contraindication to spinal or epidural anesthesia. However, in patients at increased risk of bleeding or with low body weight, PTT and thrombocyte count are necessary. Since at present no definite data exist as to the bleeding risk in patients treated with low-molecular-weight heparin prophylaxis, spinal/epidural anesthesia should be performed in controlled studies only under these conditions. This particular precaution seems to be necessary because low-molecular-weight heparin increases levels of plasminogen activators (t-PA) and therefore has fibrinolytic activity. If plasma expanders are administered perioperatively, the highest bleeding risk exists after dextran infusions. There is also an increased bleeding risk if nonsteroidal anti-inflammatory drugs, especially acetylsalicylic acid, are administered repeatedly within 5 days prior to spinal/epidural anesthesia. In these patients preoperative determination of the clotting time appears necessary.(ABSTRACT TRUNCATED AT 250 WORDS)
Anesthesia, Conduction↗
Concomitant coumarin-NSAID therapy and risk for bleeding.
OBJECTIVE: To investigate the risk of bleeding complications during the combined use of coumarin derivatives and nonsteroidal antiinflammatory drugs (NSAIDs) compared with the use of coumarin derivatives alone. SUBJECTS AND METHODS: In this 1-year observational study, the local outpatient anticoagulation office detected all coumarin users with bleeding complications. These patients were sent questionnaires regarding the type and consequences of the bleeding as well as previous NSAID use. The local pharmacists detected patients with concomitant coumarin and NSAID prescriptions (but no bleeding). The relative risk for bleeding due to concomitant coumarin and NSAID use was estimated. RESULTS: During 1 year, 738 hemorrhages were identified in 681 coumarin users. In 12.2% of these cases, an NSAID was involved. In contrast, in the whole population of coumarin users, 2.5% were prescribed an NSAID. Therefore, the relative risk of NSAID use with regard to bleeding complications was 5.8 (95% CI 2.3 to 13.6). CONCLUSIONS: NSAID use during coumarin therapy considerably increases the bleeding risk compared with coumarin therapy alone. Although in daily practice these medications are frequently prescribed concomitantly, our results underscore the contraindication of concomitant use of NSAIDs and coumarin derivatives.
Adult↗
Recombinant hirudin (lepirudin) as anticoagulant in intensive care patients treated with continuous hemodialysis.
BACKGROUND: Recombinant hirudin (lepirudin) is a potent direct thrombin inhibitor, which has been approved for the treatment of heparin-induced thrombocytopenia type II (HIT). Because the drug is mainly eliminated by the kidneys, a single loading dose of hirudin may induce therapeutic anticoagulation for up to one week in patients with renal insufficiency. Thus, the use of hirudin in critically ill patients with renal failure could markedly increase their bleeding risk. In this study, hirudin was used in critically ill patients with suspected HIT while on continuous venovenous hemodialysis (CVVHD). METHODS: Hirudin anticoagulation was performed in seven critically ill patients with suspected HIT. Four patients were initially anuric. Three patients had residual renal function. In all 64 CVVHD treatments (mean duration 12 hr), a polysulfone high-flux hemodialyzer (0.75 m2) with a dialysate flow rate of 1.5 liter/hr and an ultrafiltration rate of up to 200 ml/hr was used. Hirudin was given either as continuous intravenous infusion or as repetitive intravenous boli. Monitoring of anticoagulation was performed by measurements of the systemic activated partial thromboplastin time (aPTT). RESULTS: Hirudin dosage had to be individualized according to the risk of bleeding or clotting. During CVVHD, a continuous intravenous infusion (0.006 to 0.025 mg/kg body wt/hr, N = 2) or repetitive intravenous boli (0.007 to 0.04 mg/kg, N = 5) were given. Two patients required blood transfusions prior to and during hirudin treatment. In five patients without a high bleeding risk, the hirudin dose was adjusted to achieve the target aPTT (1.5 to 2.0 x baseline) in order to prevent thrombotic complications or frequent clotting in the extracorporal circuit. Hirudin dose requirements depended on residual renal function and extracorporal clearance. CONCLUSIONS: We conclude from these first clinical data that anticoagulation with hirudin in critically ill patients on continuous hemodialysis can be performed without excessive bleeding risk by combining close clinical and laboratory monitoring. The hirudin dose has to be reduced because of renal failure, and may require adjustment for residual or recovering renal function and extracorporal elimination.
Acute Kidney Injury↗
[Risk factors for gastrointestinal bleeding associated with low-dose aspirin].
INTRODUCTION: Low-dose aspirin is the cause of gastro-intestinal and bleeding complications. Different factors may increase the gastro-intestinal (GI) toxicity associated with aspirin. The aim of this review is to attempt to describe these factors. METHODOLOGY: This review is based on an analysis of 24 randomized GI, cardiovascular and neurological studies and 8 case-control and cohort, follow-up studies evaluating GI and bleeding risk factors associated with the ingestion of aspirin at doses of less than 500 mg/day. These studies have been selected based on specific criteria from all works published from 1983 to 2003 (PubMed). RESULTS: The GI toxicity of low-dose aspirin appears to be dose-dependent, apparently starting with 10 mg/day, but this observation has not been confirmed by all studies. The "protective" effect of gastro-resistant coating is debatable. The GI risk is enhanced in the elderly and in particular appears related to concomitant disorders, specifically cardiovascular and neurological disorders, but few studies make it possible to confirm this. A previous history of ulcer or GI bleeding are identified risk factors for GI bleeding, but few studies have been conducted on patients treated with low-dose aspirin to confirm this. Other platelet-inhibiting and anti-coagulant agents potentiate the gastro-intestinal lesional and bleeding risk associated with low-dose aspirin. GI complications are more frequent if aspirin is given in combination with conventional NSAIDs or steroids. In the case of concomitant prescription of low-dose aspirin and an NSAID, the use of a coxib may be considered, but studies are still necessary to evaluate the usefulness of their combination use with low-dose aspirin. In the future, other better tolerated NSAIDs (NO releasing NSAIDs, zwitterion complexes) will be developed. Ongoing studies evaluate the protective risk of misoprostol and proton pump inhibitors in patients at risk for a GI adverse effects, receiving low-dose aspirin. CONCLUSION: The GI risk induced by low-dose aspirin exists and may be increased by different factors related, first to the patient, and second to certain concomitant treatments. Patients at risk must be screened in order to plan a prophylactic strategy. However to date, no compound has been registered for prophylactic treatment of gastro-intestinal risk induced by low-dose aspirin.
Anti-Inflammatory Agents, Non-Steroidal↗
Hemodialysis without anticoagulants: efficiency and hemostatic aspects.
In 29 patients with high risk of bleeding, 111 hemodialyses have been performed without heparin (WHD) or other anticoagulants. The same patients were switched to low dose heparin dialysis (LDHD) as soon as the bleeding risk had ceased. The dialyzer had to be changed in 11 and the drip chamber in 20 WHDs because of partial clotting. This phenomenon did not occur during LDHD. The comparative efficiencies of the two techniques were evaluated by measuring the urea and creatinine clearances of the dialyzers. No significant difference between LDHD and WHD clearances was observed. In 7 of 29 patients, hemostasis variables were studied before, during and after both modes of treatment. Fibrinogen, platelet count, antithrombin III and prothrombin time did not differ with the different dialysis procedures. During dialysis, platelet factor 4 (PF4) levels were significantly higher than baseline values (P less than 0.01), with no difference between WHD and LDHD. Plasma fibrinopeptide A (FPA) levels remained normal during LDHD, but significantly increased during WHD (P less than 0.001). Our data indicate that WHD is feasible, with a low risk of extravascular coagulation. The bleeding risk is not increased during or after dialysis, and the danger of intravascular coagulation is low as confirmed by the isolated elevation of FPA plasma levels, unaccompanied by changes in other variables.
Acute Kidney Injury↗
Patterns of bleeding after endoscopic sphincterotomy, the subsequent risk of bleeding, and the role of epinephrine injection.
BACKGROUND: The patterns of bleeding following endoscopic sphincterotomy (ES) and their predictive value for subsequent bleeding are poorly understood. Similarly, the efficacy and side effects of epinephrine (E) injection for persistent bleeding have not been well studied. METHODS: Over a 44-month period, all patients undergoing ES were prospectively assessed and followed-up. The character of bleeding (pulsatile, oozing, trickle, none) was recorded immediately, 5 minutes following ES and at the completion of the procedure. Patients with persistent bleeding at the time the procedure was completed (5 minutes or greater) received E injection(s) (1:10,000 concentrations) into the bleeding point with a sclerotherapy needle. ES was performed in all patients with a single electrosurgical generator Valleylab (Force 1B) using pure cutting current. RESULTS: 506 patients (68% females, mean age 54 years) who underwent 550 ES were studied. Bleeding patterns immediately following ES were: 6% pulsatile, 42% oozing, 27% trickle, and 24% none. E (median 0.5 cc; range 0.5-4 cc total) was injected during 79 procedures (14%); none of these patients had complications nor delayed bleeding. For all patients, delayed bleeding occurred in 8 (1.6%, 95% CI 0.57-0.0269); of these 8 delayed bleeders, 1 had no bleeding after ES, and only 1 had any bleeding at 5 minutes. The only variable associated with bleeding after ES was abnormal labs (thrombocytopenia, elevated creatinine concentration, hypoprothrombinemia). CONCLUSIONS: The pattern of bleeding following ES may not predict the risk of late bleeding. Abnormal labs are associated with visible bleeding. Epinephrine injection is safe and appears to provide effective hemostasis.
Adult↗
Low-molecular-weight heparin as bridging anticoagulation during interruption of warfarin: assessment of a standardized periprocedural anticoagulation regimen.
BACKGROUND: The treatment of patients at increased risk for arterial thromboembolism who require temporary interruption of warfarin sodium therapy is a common clinical problem. We investigated the efficacy and safety of a standardized periprocedural anticoagulation regimen with low-molecular-weight heparin. METHODS: We studied 650 consecutive patients with a mechanical heart valve, chronic atrial fibrillation, or embolic stroke who required interruption of warfarin therapy because of an invasive procedure. Warfarin was stopped 5 or 6 days before the procedure, and patients received subcutaneous dalteparin sodium, 100 IU/kg twice daily, starting 3 days before the procedure. The risk of postprocedural bleeding determined postprocedural anticoagulant management. In patients undergoing a non-high-bleeding-risk procedure who had adequate postprocedural hemostasis, warfarin was resumed on the evening of the procedure, and dalteparin sodium, 100 IU/kg twice daily, was resumed on the next day and continued until the international normalized ratio was 2.0 or more. If postprocedural hemostasis was not secured, the resumption of dalteparin was delayed. In patients undergoing a high-bleeding-risk procedure, warfarin was resumed on the evening of the procedure, but dalteparin was not given after the procedure. RESULTS: Patients were followed up during the preprocedural and postprocedural period for a mean of 13.8 days (range, 10-18 days). In 542 patients who underwent a non-high-bleeding-risk procedure, there were 2 thromboembolic events (0.4%), 4 major bleeding episodes (0.7%), and 32 episodes of increased wound-related blood loss that precluded postprocedural dalteparin administration (5.9%). In 108 patients who underwent a high-bleeding-risk procedure, there were 2 deaths (1.8%) possibly due to thromboembolism and 2 major bleeding episodes (1.8%). CONCLUSIONS: In patients at increased risk for arterial thromboembolism who require temporary interruption of warfarin therapy, a standardized periprocedural anticoagulant regimen with low-molecular-weight heparin is associated with a low risk of thromboembolic and major bleeding complications.
Adult↗