ABSTRACT
Abstract Background Diagnosis of pulmonary embolism (PE) constitutes a challenge for practitioners. Current practice involves use of pre-test probability prediction rules. Several strategies to optimize this process have been explored. Objectives To explore whether application of the pulmonary embolism rule-out criteria (PERC rule) and age-adjusted D-dimer (DD) would have reduced the number of computed tomography pulmonary angiography (CTPA) examinations performed in patients with suspected PE. Methods A retrospective cross-sectional study of adult patients taken for CTPA under suspicion of PE in 2018 and 2020. The PERC rule and age-adjusted DD were applied. The number of cases without indications for imaging studies was estimated and the operational characteristics for diagnosis of PE were calculated. Results 302 patients were included. PE was diagnosed in 29.8%. Only 27.2% of 'not probable' cases according to the Wells criteria had D-dimer assays. Age adjustment would have reduced tomography use by 11.1%, with an AUC of 0.5. The PERC rule would have reduced use by 7%, with an AUC of 0.72. Conclusions Application of age-adjusted D-dimer and the PERC rule to patients taken for CTPA because of suspected PE seems to reduce the number of indications for the procedure.
Resumo Contexto O diagnóstico de embolia pulmonar (EP) representa um desafio para o profissional. A prática atual envolve o uso de modelos de previsão de probabilidade pré-teste e, para otimizar esse processo, várias estratégias têm sido exploradas. Objetivos Investigar se a aplicação dos critérios de exclusão de EP (pulmonary embolism rule-out criteria, PERC) e do D-dímero (DD) ajustado para idade diminui o número de angiografias computadorizadas (ATCs) pulmonares realizadas em pacientes com suspeita de EP. Métodos Estudo transversal retrospectivo com pacientes adultos submetidos a ATC pulmonar com suspeita de EP em 2018 e 2020. Foram aplicados os critérios PERC e o DD ajustado para idade. Foi estimado o número de casos não indicados para exames de imagem, e foram calculadas as características operacionais para o diagnóstico de EP. Resultados Foram incluídos 302 pacientes, dos quais 29,8% apresentaram diagnóstico de EP. Apenas 27,2% dos casos não prováveis de acordo com os critérios de Wells apresentaram DD; o ajuste implicou em uma diminuição de ACTs de 11,1%, com área sob a curva de 0,5. Os critérios PERC diminuiriam em 7%, com área sob a curva de 0,72. Conclusões A aplicação do DD ajustado para idade e dos critérios PERC em pacientes submetidos a ATC pulmonar por suspeita de EP parece diminuir a indicação para tais exames.
ABSTRACT
Objective To investigate the effects of different dose of tranexamic acid in fibrinolysis during liver transplantation. Methods Sixty ASA Ⅱ~ Ⅳ liver transplant recipients, were randomly, double-blind assigned to one of 3 groups (n = 20): group control (group C), group tranexamic acid 1 (group T1) and group tranexamic acid 2 (group T2). The patients in group C received a loading dose of normal saline 10 mL, then continued infuse normal saline at 20 mL/h until neohepatic phase 120 min, while in other two groups, patients received a loading dose of tranexamic acid 1 g, totally 10 mL, followed by continuous infusion at 10 mg/(kg·h) in group T1 or 20 mg/(kg·h) in group T2 until neohepatic phase 120 min. Prothrombin time, fibrinogen, fibrin degradation product and D-dimers were measured before operation (T0), 120 min after the skin incision (T1), nonhepatic phase 30 min (T2), neohepatic phase 120 min (T3). Blood loss, fresh frozen plasma dosage, fibrinogen dosage and thromboembolic events were recorded. Results The plasma concentration of fibrin degradation product and plasma concentration of D-dimers were different in the 3 groups, group T2 0.05). Conclusions Continuous infusion of tranexamic acid can inhibit fibrinolysis during liver transplantation. No adverse event of thrombosis was detected. Larger dose of tranexamic acid can reduce blood loss and fresh frozen plasma transfusion.
ABSTRACT
<b>Objective</b> : Although an endoleak is the most common complication after endovascular abdominal aortic aneurysm repair (EVAR), the proper and noninvasive method for the detection of endoleaks is not established. The purpose of this study is to investigate whether plasma levels of D-dimer and fibrin degradation product (FDP) could be predictors of endoleaks after EVAR. <b>Methods</b> : Between June 2011 and January 2014, 65 consecutive patients underwent EVAR at our institution. We evaluated 55 patients excluding 10 patients pre-existing conditions such as aortic dissection, arterial or venous thrombosis, conversion to open surgery, and difficulties in making outpatient visits. Enhanced computed tomography (CT) examination was performed during 12 months after EVAR. Persistent endoleaks and maximum aneurysmal diameter were evaluated at each follow-up time. Patients were divided into groups according to CT findings at 12 months after EVAR. There were 26 patients with endoleaks vs. 29 non-endoleak patients, 34 with unchanged aneurysm findings vs. 21 with shrinkage. No patient showed aneurysmal enlargement. Plasma levels of D-dimer, FDP, counts of platelet, prothrombin time (PT), and activated partial thromboplastin time (APTT) were also measured at the time of CT examinations. <b>Results</b> : There was no operative death and no major complication. Endoleaks in all patients were identified as type II. None of them required re-intervention. In the endoleak group, plasma levels of D-dimer and FDP were significantly higher than in the non-endoleak group in each postoperative period. In addition, postoperative counts of platelet were significantly lower in the endoleak group. PT and APTT test results showed no significant difference in the two groups. In the unchanged aneurysm group, postoperative D-dimer and FDP tended to be higher compared with the shrinkage group. Postoperative counts of platelet also tended to be lower in the unchanged group. There were no differences in PT and APTT test results. <b>Conclusion</b> : Plasma levels of D-dimer and FDP are potentially useful predictors of endoleaks after EVAR.
ABSTRACT
The anesthesiologist is sometime presented with the problem of coagulation defects through the perioperative period. The possible causes of inappropriate hemostasis in this situation are numerous, and multiple mechanism may be simultaneously involved. Coagulation and fibrinolysis variables were measured in 15 patients who had undergone prolonged major surgery or received massive transfusion before and until 10 days after operation. Hemostactic surveys included platelet count, fibrinogen, prothrombin time, activated partial thromboplastin time, antithrombin lll, and fibrin degraduation products. No patients had major hemorrhage, thrombosis, or disseminated intravascular coagulation, but laboratory findings suggest that a hypercoagulable state existed even 10 days postoperatively. The results were as follows: 1) Platelet counts decreased just after operation, but significantly increased to 154% of the control value 7 days after operation and 204% 10 days postoperatively. 2) Prothrombin time was significantly prolonged just after operation compared to the control value, but returned to normal in 4 days postoperatively. 3) Fibrinogen decreased just after operation, but significantly increased to 165% of the control value 4 days after operation, 178% 7days after operation and 191% 10 days postoperatively. 4) Activated partial thromboplastin time was not changed through the entire period. 5) Antithrombin lll was not changed through the entire period. 6) Fibrin degradation product was within normal ranges before operation, but in 11 cases it exceeded normal range from 1 to 10 days postoperatively.