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In a dinner symposium that was conducted at the 47th American Society of Health-System Pharmacists (ASHP), Midyear Clinical Meeting and Exhibition: Jerrold H. Levy, MD, FAHA, FCCM; and Bradley A. Boucher, PharmD, FCCP, FCCM, BCPS, discussed the different types of systemic and topical hemostatic agents available to achieve hemostasis in the surgical setting. Also included, is a discussion on the physiology of hemostasis and the impact of anticoagulants on the coagulation cascade.
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Credits: 1.25 CME | Expires: 12/2013
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In a breakfast symposium that was held independently of the official Scientific Assembly of the American College of Emergency Physicians (ACEP), Joshua N. Goldstein, MD, PhD, FACEP, FAAEM, FAHA; David A. Garcia, MD; and Mark Walsh, MD, FACEP, discussed the clinical presentation, diagnosis, and current therapeutic interventions of acquired coagulopathy in patients with bleeding while experiencing trauma, undergoing elective surgery, or receiving anticoagulant therapy.
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Widespread use of anticoagulants has led to an increase in bleeding episodes seen in emergency departments. The best strategy for reversal of coaguloathy associated with warfarin-related bleeding is still under debate. In a dinner symposium held in conjunction with the Annual Meeting of the Society for Academic Emergency Medicine, W. Frank Peacock, MD; Bryan A. Cotton, MD, MPH; and David A. Garcia, MD, discussed the interpretation of current coagulation assays and their impact on clinical decisions; best practices for the rapid reversal of anticoagulant-associated intracerebral hemorrhage; and the reversal of acute traumatic coagulopathy in patients presenting to the emergency department.
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This Clinical Brief is a discussion on whether plasma fibrinogen is a biomarker for perioperative bleeding in patients undergoing cardiovascular procedures. Key discussion points include why preoperative measurement of fibrinogen concentration is an important indicator of complications from excessive bleeding and ultimately, outcomes. Early identification of patients, who are at increased risk of excessive bleeding, can help the surgical team assess potential transfusion requirements and, in turn, develop more effective strategies for restoring and maintaining perioperative hemostasis. In addition, the Clinical Brief reviews recent data, which suggests that fibrinogen plays a critical role in achieving and maintaining hemostasis, particularly in patients in whom acquired fibrinogen deficiency develops during massive hemorrhage. At the end of the Clinical Brief, you may elect to click on either of the two CME activities about current trends in coagulation and managing coagulopathy in elective and urgent cardiac surgery.
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Bleeding during cardiac surgery remains a major concern for cardiac surgeons and anesthesiologists because excessive bleeding often leads to transfusion of allogeneic blood and blood components, as well as reexploration ─ all of which contribute to complications and negative outcomes. Coronary artery bypass grafting (CABG) surgery is the most common cardiac surgery performed in the United States, with approximately 500,000 procedures performed annually. Cardiopulmonary bypass (CPB), which is used in most surgeries of this type, may be associated with the development of coagulopathy that increases the risk of bleeding. These procedures are a significant cause of morbidity and mortality because they frequently involve major bleeding. Most hemostatic factors are intercorrelated with postoperative bleeding and several experts indicate that fibrinogen deficiency is the most fundamental hemostatic risk factor for cardiac surgical procedures. The Blood CME Center surveyed cardiovascular and thoracic anesthesiologists, cardiac surgeons, and critical care nurses to learn more about their management of perioperative bleeding, utilization of blood factor products, and restoring hemostasis. Review the survey findings in this Clinical Brief; then, you may elect to click on either of the two CME activities about current trends in coagulation and managing coagulopathy in elective and urgent cardiac surgery.
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Is fibrinogen deficiency a fundamental risk factor for cardiac surgery? The Blood CME Center posed this question to Aryeh Shander, MD, a leading anesthesiologist and blood conservation advocate, who provided both perspective and personal experience managing cardiac surgery patients who present with risk factors for excessive perioperative bleeding. Dr. Shander reviews and explains the findings from several studies that examined fibrinogen substitution therapy in patients with massive hemorrhage and low plasma fibrinogen concentrations, factor replacement therapies that improve clot formation in the surgical patient, and the clinical impact of fibrinogen level, bleeding, and outcomes in patients undergoing cardiac procedures. Noting that preoperative fibrinogen concentration, female gender, and aortic cross-clamp time were independent predictors of transfusion, Dr. Shander indicated that preoperative measurement of fibrinogen could potentially be used to assess the risk of bleeding and cited emerging data from Europe that support the implementation of measuring preoperative fibrinogen concentration as standard procedure, particularly in the cardiothoracic surgery population. At the end of this Clinical Brief, you may elect to click on either of the two CME activities about current trends in coagulation and managing coagulopathy in elective and urgent cardiac surgery.
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When excessive bleeding occurs, it is imperative that effective strategies be employed as quickly as possible to restore and maintain hemostasis. In this brief, Dr. Mark Ereth describes a case of uncontrolled bleeding with no immediately identifiable cause in a patient following thoracic aortic aneurysm repair. What steps should the surgical team take to restore hemostasis?
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Are there hemostatic challenges unique to cardiac surgery? An anesthesiologist and a surgeon discuss important factors in perioperative cardiac bleeding and the clinician’s ability to mitigate against those factors in this informative Q&A exchange. Topics covered include strategies for managing hemostasis; the debate concerning optimal fibrinogen levels; benefits and drawbacks to using allogeneic blood products for the correction of low fibrinogen levels; how to measure clot formation intraoperatively and postoperatively; as well as recent developments in point-of-care diagnostics, including ROTEM, and how these developments will likely impact the perioperative management of hemostasis.
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The list of anticoagulants used in the United States is growing, with several agents recently approved in the last decade and numerous others awaiting approval. Cardiothoracic anesthesiologist Jerrold H. Levy offers insights on both conventional and novel anticoagulants and the challenges they pose for clinicians who must manage the hemostatic stability of their patients in emergent situations or when urgent invasive procedures are required. This learning activity explores issues in anticoagulant therapy, including risks and benefits of old and new agents, strategies for reversal of therapy, and ways to monitor reversal of anticoagulant effects.
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Nearly 1½ centuries ago, the clinical manifestations of drug-induced thrombocytopenia (DIT) were first described. Since that time, the disorder has become increasingly common. Despite the availability of testing to identify implicated agents in DIT, a high index of suspicion and a patient history of drug exposure remain important elements of effective assessment and management. Patricia A. Ford, MD, examines the various mechanisms of this disorder as well as new and upcoming treatments for it.
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In the United States, the demand for donated organs far exceeds the supply. In this learning activity, Deborah M. Stein, MD, MPH, FACS, draws on research she has conducted with colleagues at the R Adams Cowley Shock Trauma Center concerning successful organ donation among patients with nonsurvivable traumatic brain injury and severe coagulopathy or active hemorrhage. Approximately 3 of every 4 organs transplanted are removed from deceased donors. Dr. Stein focuses on the ways that patients with devastating neurologic outcomes are clinically managed to allow for successful donation, and she addresses ethical and economic considerations.
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Coagulopathy is often a life-threatening complication in trauma patients. This activity looks at two studies that evaluated strategies for limiting blood transfusion and administration of large volumes of other resuscitative fluids while improving patient outcomes.
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Trauma surgeons Bryan A. Cotton and Martin A. Schreiber participate in a Q&A exchange on conventional and emerging strategies for managing the coagulopathy of trauma. Long regarded as iatrogenic in nature, the coagulopathy of trauma is now being recognized as a condition that occurs almost immediately following injury. In this podcast activity, Drs. Cotton and Schreiber draw on their many years of combined experience in trauma and critical care surgery to comment on the shifting treatment paradigm and field questions on such issues as clinician perceptions regarding trauma coagulopathy, treatment protocols, blood product ratios, and future directions in trauma care.
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Trauma anesthesiologist Richard P. Dutton, MD, MBA, draws on his clinical experiences at the R Adams Cowley Shock Trauma Center, the largest-volume trauma center in the United States, to discuss the coagulopathy of trauma and the ways in which treatment strategies for this condition have evolved over time. Clinicians’ understanding of the coagulopathy of trauma has advanced over the past 5 to 10 years. In this podcast activity, Dr. Dutton specifically addresses the early coagulopathy of trauma as a distinct entity, damage control surgery, resuscitation strategies and the use of antifibrinolytic therapies, and the future role of recombinant factor VIIa in resuscitation and coagulopathy.
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In this Q&A interview, Aryeh Shander, MD, FCCM, FCCP, discusses the challenges that preoperative anemia presents to surgical team members and other clinicians. As part of this podcast, Dr. Shander addresses the association between outcomes and etiology of anemia, the importance of low hemoglobin level and symptoms in the treatment of preoperative anemia, and therapeutic choices for patients with preoperative anemia that is associated with chronic comorbidities such as kidney disease, HIV, and sickle cell disease.
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Blood management expert Jerrold Levy, MD, FAHA, addresses questions concerning today’s therapeutic options for achieving and maintaining intraoperative hemostasis. As part of this activity, Dr. Levy discusses current recommendations for selecting topical agents and the value of hemostatic tests both inside and outside of the OR. Additional topics discussed by Dr. Levy include the clinical significance of acquired coagulopathy secondary to bovine thrombin exposure, individual dynamics that may predispose a patient to intraoperative bleeding, and the challenges of maintaining hemostasis in the surgical setting.
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Trauma care specialists Richard P. Dutton, MD, MBA; John B. Holcomb, MD, FACS; and Deborah M. Stein, MD, MPH, FACS; address questions on such topics as the role of coagulopathy in trauma, pitfalls of early aggressive treatment, and ways to improve patient outcomes. A major development in trauma care over the past 5 years has been the recognition that coagulopathy is an important component of early trauma, and the level of coagulopathy present at the time of admission correlates with outcomes among seriously injured trauma patients. What has been learned in the trauma care setting about coagulopathy has relevance to and application in other surgical disciplines.
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Listen to Richard P. Dutton, MD, MBA, in this archived version of a previously recorded Webinar, discuss hemostatic challenges and the tools with which perioperative impairment of hemostasis may be restored. The case-based activity presents a surgical challenge for assessment and review by surgeons and anesthesiologists, who offer insights on how to manage complications attributed to bleeding and clotting.
This archived Webinar was recorded during a live CME Webinar that was held on April 23, 2008.
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Richard P. Dutton, MD, MBA; John B. Holcomb, MD, FACS; and Deborah M. Stein, MD, MPH, FACS; discuss the evolving clinical perceptions of acquired coagulopathy and how it is treated. As part of their discussion, these trauma specialists address the use of prohemostatic agents in military and civilian practice, hypotensive resuscitation practices, and standard procedures for utilizing off-label recombinant factor VIIa.
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Listen to Maureane Hoffman, MD, PhD, discuss the risks associated with blood transfusion and the clinical indicators for this treatment modality. As part of her discussion, Dr. Hoffman addresses the role of treatment guidelines and laboratory values in the decision to transfuse, techniques to reduce transfusion, and uses of nontransfusional therapies.
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Listen to Jeffrey H. Lawson, MD, PhD, share his views on the management of excessive bleeding in surgical patients, with a focus on vascular surgery. Dr. Lawson offers a philosophical perspective on hemostatic issues ranging from transfusion concerns and the practice of bloodless medicine to new strategies for achieving optimal hemostasis. Based, in part, on his experience as Director of Duke University’s Vascular Surgery Research Lab,
Dr. Lawson also outlines a paradigm for achieving hemostatic stability in surgical patients.
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Ref No
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Description
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049
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“Achieving Hemostasis in the Surgical Field: A Multidisciplinary Team Approach to Pharmacotherapy”
Achieving Hemostasis in the Surgical Field
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048
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“Challenging Cases of Acquired Coagulopathy Encountered in the ED”
Acquired coagulopathy in bleeding patients
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047
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“Coagulopathy in the Non-Trauma and Trauma Settings”
Learning activity addresses acquired coagulopathy in the non-trauma and trauma settings
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046
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“Coagulopathy in Patients Undergoing Elective or Emergent Surgery”
Learning activity addresses acquired coagulopathy in patients undergoing elective or emergent surgery
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045
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“Pros and Cons of Managing Oral Anticoagulant-Associated Hemorrhages and Acute Traumatic Coagulopathy”
Learning activity concerning the management of acute traumatic coagulopathy and anticoagulant-associated hemorrhage in the emergency department
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043
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“Clinical Perspectives: When Fibrinogen Deficiency Complicates Surgical Hemostasis”
Presentation on fibrinogen deficiency and excessive bleeding
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042
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“Current Trends in Coagulation: The Correlation Between Fibrinogen Levels and Surgical Hemostasis”
Is fibrinogen deficiency a fundamental risk factor for cardiac surgery? In an interview with Blood CME Center staff, Aryeh Shander, MD, FCCM, FCCP, offers his expert opinion on the role of fibrinogen in surgical hemostasis. As part of his discussion, Dr. Shander reflects on recent data correlating fibrinogen levels with the risk of bleeding, particularly in the cardiac surgery population, as well as current and emerging strategies for achieving and maintaining optimal hemostasis
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041
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“Challenges in Perioperative Hemostasis: Managing Coagulopathy in Elective and Urgent Cardiac Surgery”
Presentation on managing perioperative hemostasis in cardiac patients
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040
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“Elective Orthopedic Surgery in Patients With Inhibitors: The Hematologist/Orthopedic Surgeon Consult”
Expert commentary on orthopedic surgery in hemophilia A patients with inhibitors
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039
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“Challenges in Perioperative Hemostasis: Managing Coagulopathy in Elective and Urgent Cardiac Surgery”
Expert commentary on hemostatic challenges of cardiac surgery
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037
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“Managing Hemostasis in an Era of Conventional and Novel Anticoagulants”
Monograph on anticoagulant therapy
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036
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“Multidisciplinary Team Care in Hemophilia: Elective Orthopedic Surgery in Patients With Inhibitors”
Presentation from the National Hemophilia Foundation Symposium
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035
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“Drug-Induced Thrombocytopenia: New Options and Treatment Strategies”
Review of the diagnostic strategies and treatments for drug-induced thrombocytopenia
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034
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“Managing the Coagulopathy of Trauma: Use of Transfusion Protocols and Prohemostatic Agents”
Presentation on benefits of transfusion protocols.
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033
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“Decisions in Trauma Care: Managing Coagulopathy to Facilitate Organ Donation”
Presentation on the management of coagulopathy to facilitate organ donation.
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032
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“Interpreting the Coagulopathy of Trauma-Shock”
Presentation on the mechanisms that contribute to the acute coagulopathy of trauma.
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031
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“Can Less Be More in Trauma? Editor’s Picks”
Literature synopses on resuscitation strategies in trauma
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030
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“Practical Strategies for Managing Perioperative Anemia: Surgical Implications and Therapeutic Options”
Presentation on the management of perioperative anemia
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029
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“Q&A: Current Protocols and Future Strategies for Managing the Coagulopathy of Trauma”
Q&A on managing the coagulopathy of trauma
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028
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“Q&A: Evolving Strategies in the Treatment of the Coagulopathy of Trauma”
Q&A on the coagulopathy of trauma
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027
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“Pressing Issues About Preoperative Anemia”
Q&A session on preoperative anemia
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026
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“Practical Strategies for Managing Perioperative Anemia: Screening and Presurgical Treatment”
Presentation on the management of perioperative anemia
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025
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“Q&A: What Makes Trauma Patients Coagulopathic?”
Q&A on mechanisms of trauma coagulopathy
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024
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“An Acquired Bleeding Disorder in the Perioperative Setting”
Case study on diagnosis and treatment of acquired inhibitors to factor VIII
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023
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“Q&A: Spontaneous Inhibitors to Factor VIII: Managing the Clinical Challenges of an Acquired Bleeding Disorder”
Q&A on acquired inhibitors to factor VIII
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022
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“Controversies in Selecting Topical Hemostatic Agents”
Presentation on the controversies and options for controlling intraoperative bleeding with topical hemostatic agents.
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021
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“Question & Answer Session: Hemostatic Agents”
Question & Answer session on the controversies and options for controlling intraoperative bleeding with topical hemostatic agents.
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020
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“Acquired Hemophilia in and out of the Surgical Setting
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Case-based and didactic learning on the management of acquired hemophilia.
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019
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“Congenital Hemophilia A With Inhibitors: Managing the Emergent Situation
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Case-based and didactic learning on the management of congenital hemophilia.
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018
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“Acquired Factor VIII Inhibitors as a Precipitating Cause of Postpartum Hemorrhage”
Presentation on the identification and clinical management of postpartum acquired hemophilia.
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017
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“VCU Pauley Heart Center: Blood Conservation Measures”
Vigneshwar Kasirajan, MD, a cardiothoracic surgeon at the VCU Pauley Heart Center, discusses that institution’s blood conservation program in cardiac surgery, as part of this Practicing Excellence in Transfusion (PET) activity.
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016
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“The Aprotinin Controversy: A Review of the Evidence”
As part of the Practicing Excellence in Transfusion (PET) program, Bruce D. Spiess, MD, FAHA, evaluates the aprotinin controversy in light of seminal clinical trials.
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015
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“Blood Management in Cardiac Surgery”
As part of the Practicing Excellence in Transfusion (PET) program, Victor A. Ferraris, MD, PhD, discusses evidence-based blood conservation strategies in clinical practice.
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014
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“Hemostasis for the Surgeon: Treatment Practices”
Cardiothoracic surgeon Peter K. Smith reviews the risks and benefits of available prohemostatic agents used by the surgeon to treat acquired coagulopathy.
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013
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“Hemostasis for the Anesthesiologist: Treatment Practices”
Richard P. Dutton, MD, MBA, shares an anesthesiologist’s perspective on some of the challenges to normal hemostasis, as well as treatments and procedures for the intraoperative and postoperative management of acquired coagulopathy.
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012
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“The Physiology of Hemostasis”
Ira A. Shulman, MD, a pathologist/transfusion specialist, presents on the evolving model of the coagulation cascade and the 4 phases of the hemostatic process, including vascular spasm and fibrinolysis. As part of this exploration, transfusion practices and the potential prothrombotic effects of platelets are addressed.
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011
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“Hemorrhagic Shock”
Presentation on the potential consequences of traumatic combat injury and hemorrhagic shock.
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010
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“Strategies for Preventing and Treating Uncontrolled Perioperative Bleeding—Archived Webinar”
Richard P. Dutton, MD, MBA, is featured in this archived version of a previously recorded live CME Webinar that addresses the prevention and management of uncontrolled perioperative bleeding.
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009
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“Traumatic Brain Injury”
Deborah M. Stein, MD, MPH, FACS, discusses aspects of traumatic brain injury.
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008
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“What Is the Difference Between Blood and Chicken Soup? ”
Maureane Hoffman, MD, PhD, shares her views on transfusion, including possible risks and alternative treatments.
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007
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“The Road to Optimal Hemostasis Bibliography”
References from The Road to Optimal Hemostasis: Avoiding Misadventures in Bleeding and Thrombosis program.
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006
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“The Biology of Bleeding and Clotting to Death”
Dr. Jeffrey H. Lawson’s presentation from The Road to Optimal Hemostasis: Avoiding Misadventures in Bleeding and Thrombosis program.
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005
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“Management of Bleeding in Cardiac Surgical Patients”
Dr. Jerrold H. Levy’s presentation from The Road to Optimal Hemostasis: Avoiding Misadventures in Bleeding and Thrombosis program.
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004
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“Excessive Bleeding in the Surgical Patient”
Vascular surgeon Jeffrey H. Lawson, MD, PhD, expresses his views on the management of excessive bleeding in surgical patients.
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003
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“Strategies for Preventing and Treating Uncontrolled Perioperative Bleeding”
This interactive visiting faculty series, led by experts in blood management, combines didactic learning with specialty-specific case evaluations on the prevention and management of uncontrolled perioperative bleeding.
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002
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“Identification and Management of Surgical Patients at Risk for Coagulopathy”
In a Q&A format, Dr. Jerrold Levy explores issues relevant to surgical patients at risk for coagulopathy.
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001
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“Acquired Coagulopathy in Cardiothoracic and Vascular Surgery”
Drawing on his expertise as a cardiothoracic anesthesiologist, Dr. Jerrold Levy discusses the prevention and management of surgical coagulopathy.
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