New and old oral anticoagulants in anesthesia practice: a balancing approach

For decades, vitamin K antagonist warfarin has been used for thromboprophylaxis or stroke prevention in atrial fibrillation. Recently, direct thrombin inhibitor - dabigatran and factor Xa inhibitors - rivaroxaban and apixaban, have emerged as alternatives to warfarin. The perioperative management of antithrombotic therapy involves establishing a balance between hemorrhagic risk and thrombotic risk. Routine coagulation assays like prothrombin time and activated partial thromboplastin time provide a crude estimation of their activity. Further, no specific antidotes are available to reverse their effect. These drugs are discontinued before elective surgery and timing is based on the patient's renal status also. For emergency surgery or bleeding, the management includes the principles of bleeding control; hemodialysis may be effective for dabigatran. Prothrombin complex concentrates are found to be more effective than frozen plasma but more studies are warranted

Assessment of hemostatic changes after crystalloid and colloid fluid preloading in trauma patients using standard coagulation parameters and thromboelastography

The choice of an ideal fluid administered post trauma and its subsequent influence on coagulation still poses a clinical dilemma. Hence, this study was designed to assess the influence of in vivo hemodilution with various fluid preparations [4% gelatin, 6% hydoxyethyl starch [HES], Ringer's lactate, 0.9% normal saline] on coagulation using standard coagulation parameters and real-time thromboelastography [TEG] in patients undergoing elective surgery post trauma. In a randomized, double-blind study, 100 patients of either sex and age, belonging to ASA Grades I and II, scheduled for elective surgeries were allocated into four groups of 25 each according to the type of fluid infused. Group G [4% gelatin], Group N [0.9% normal saline], Group R [Ringer's lactate], and Group H [6% HES] received preloading with 1 L of fluid according to the group. The coagulation status of the patients was assessed during perioperative period [before surgery, after fluid preloading, and at the end of the surgery] using both conventional coagulation analysis and TEG. Analysis of variance [ANOVA], post hoc and Pearson Chi-square test were used. In all the patients preloaded with gelatin, there was a significant increase in prothrombin time index [PTI; 14.88 +/- 0.90 vs. 13.78 +/- 3.01, P<0.001] and international normalized ratio [INR; 1.12 +/- 0.09 vs. 1.09 +/- 0.19, P<0.05] compared to the baseline value. An increase was observed in these parameters in the postoperative period also. In the HES group, there was statistically significant increase in PT time [15.70 +/- 1.51 vs. 13.74 +/- 0.75, P=0.01] and INR [1.20 +/- 0.15 vs. 1.03 +/- 0.17, P<0.001] as compared to the baseline. In the intergroup comparisons, the patients preloaded with HES had a significant increase in INR [1.20 +/- 0.15 vs. 1.12 +/- 0.09, P=0.04] and reaction time [R time; 6.84 +/- 2.55 min vs. 4.79 +/- 1.77 min, P=0.02] as compared to the gelatin group. The fall in coagulation time [k time; 2.16 +/- 0.98 vs. 3.94 +/- 2.6, P=0.02], rise in maximum amplitude [MA; 61.94 +/- 14.08 vs. 50.11 +/- 14.10, P=0.04], and rise in A20 [56.17 +/- 14.66 vs. 43.11 +/- 14.24, P=0.05] were more in patients preloaded with RL as compared to the HES group. 100% patients in the gelatin group, 84.2% patients in the NS group, 94.4% patients in the RL group, and 66.7% patients in the HES group had hypocoagulable [R time > 14 min] state in the postoperative period. Crystalloids are optimal volume expanders in trauma, with RL having beneficial effects on coagulation system [decrease in k time and increase in MA and A20]. Among the colloids, HES 6% [130/0.4] affects coagulation parameters [increase in PTI, INR, R time, k time] more than gelatin. Trial registration [protocol number-IEC/NP-189/2011]

Carinal injury: an airway challenge for anesthesiologists

Tracheobronchial disruption is a potentially life-threatening airway challenge for all the anesthesiologists. Carinal rents, although rare, if not timely managed can be catastrophic. We describe a patient with carinal rent being managed successfully by prompt diagnosis, use of low pressure ventilation, and bronchoscopic sealing using tissue glue