Proposal for the management of COVID-19-associated coagulopathy in children / Propuesta para el manejo de la coagulopatía asociada a COVID-19 en niños

Abstract SARS-CoV-2 infection (COVID-19) has become a pandemic with a high case fatality rate that mainly affects adults. Most severely ill adult patients develop a coagulopathy that was not described until recently, and which is currently considered a main cause of death. Everything indicates that a similar phenomenon also occurs in children with COVID-19. Anticoagulant treatment has become one of the therapeutic foundations for this infection; however, its implementation in children can be difficult since, until recently, it was not considered in the pediatric population. Evidence regarding the use of anticoagulants in COVID-19 is rapidly generated, changes constantly, it is often difficult to interpret, and can be contradictory. After an extensive review of the published literature, a proposal was generated that offers suggestions for anticoagulant treatment, considering available resources in Mexico.

Resumen La infección por SARS-CoV-2 (COVID-19) se ha constituido en una pandemia con alto índice de letalidad que afecta principalmente a los adultos. La mayor parte de los pacientes adultos graves desarrolla una coagulopatía que no estaba descrita, la cual actualmente se considera la principal causa de muerte. Todo indica que un fenómeno parecido ocurre también en el niño con COVID-19. El tratamiento anticoagulante se ha convertido en uno de los fundamentos terapéuticos de esta infección; sin embargo, su establecimiento en el niño puede ser difícil ya que, hasta hace poco, no estaba considerado en la población pediátrica. La evidencia respecto al uso de anticoagulantes en COVID-19 se genera con rapidez, cambia constantemente, con frecuencia es difícil de interpretar y puede ser contradictoria. Después de una extensa revisión de la literatura publicada, se generó una propuesta que ofrece sugerencias para el tratamiento anticoagulante en la que se consideran los recursos disponibles en México.

Association between hypocalcemia and rivaroxaban in coagulation disorders: a case report / Associação entre hipocalcemia e rivaroxaban em distúrbios de coagulação: relato de caso

ABSTRACT We describe a patient with tertiary hyperparathyroidism with history of three episodes of deep vein thrombosis and on rivaroxaban. The patient underwent a subtotal parathyroidectomy, developing cervical hematoma with airway compression. Therefore, emergency surgical decompression was necessary. Later, on the ninth postoperative day, the serum ionized calcium levels were low. Medical team knowledge about preexisting diseases and their implication in the coagulation state are essential conditions to reduce morbidity and mortality of surgeries. However, no reports were found in literature about the association of hypocalcemia with the use of the new class of anticoagulants, which act as factor X inhibitors (Stuart-Prower factor), predisposing to increased bleeding in the immediate postoperative period.

RESUMO Descrevemos um paciente com hiperparatireoidismo terciário com história de três episódios de trombose venosa profunda e em uso de rivaroxabana. O paciente foi submetido a uma paratireoidectomia subtotal, desenvolvendo hematoma cervical com compressão das vias aéreas. Foi necessária descompressão cirúrgica de emergência. No nono dia de pós-operatório, os níveis séricos de cálcio iônico estavam baixos. O conhecimento da equipe médica sobre doenças preexistentes e de sua implicação no estado de coagulação é condição indispensável para a redução da morbimortalidade do procedimento cirúrgico. No entanto, não há relatos na literatura associando hipocalcemia com o uso da nova classe de anticoagulantes que atuam como inibidores do fator X (fator de Stuart-Prower), predispondo ao aumento do sangramento no pós-operatório imediato.

Anesthetic management for combined mitral valve replacement and aortic valve repair in a patient with osteogenesis imperfecta.

Osteogenesis imperfecta is a rare disorder of connective tissues and presents multiple challenges, including difficult airway, hyperthermia, coagulopathy and respiratory dysfunction, for anesthesiologists, especially during cardiac surgery. We present anesthetic management of a patient with osteogenesis impertecta during double valve surgery. Dexmedetomidine infusion minimized the risks of malignant hyperthermia. Glidescope and in-line stabilization facilitated endotracheal intubation and protected his oral structures and cervical spine. Transesophageal echocardiography (TEE) diagnosed a flail A3 segment and redundant left coronary cusp causing mitral and aortic regurgitation. The mitral valve was replaced and the aortic valve repaired. Coagulopathy was corrected according to comprehensive coagulation analysis. Glidescope, dexmedetomidine, coagulation analysis and TEE could facilitate anesthetic management in these patients.

Rational use of anti-snake venom (ASV): trial of various regimens in hemotoxic snake envenomation.

BACKGROUND: Viperine snake bites cause hemotoxicity in the form of coagulation dysfunction. Optimal dose requirement of anti-snake venom (ASV) and duration of therapy in such situation have not yet been fully explored. Our aim in this study was to compare two low-dose continuous infusion regimes with the standard high dose intermittent bolus regime in treating systemic envenomation and preventing its recurrence. METHODS: A prospective interventional study was conducted on 90 adult patients with snake bite with hemotoxicity. Patents were allocated into three treatment regimes, each regime being tried on 30 patients. Regimen I (standard high dose regimen) consisted of conventional, intermittent bolus dosage of 100 ml of ASV as a loading dose followed by 50 ml every six hours till whole blood coagulation time (CT) became normal. Regimen II consisted of 30 ml of ASV as a loading dose followed by 30 ml continuous infusion every six hours till two CTs at an interval of six hours were normal and a further dose of 30ml over 24 hours. Regimen III was similar to Regimen II in all aspects except that loading dose was 70 ml (instead of 30 ml). RESULTS: In patients with mild envenomation, even though the average requirement of ASV was only marginally lower in Regimen II (128.6 ml) as compared to in Regimen I (137.5 ml), one patient on Regimen I had relapse of coagulation dysfunction. In patients with moderate envenomation, average requirement of ASV was 221.3 ml and 179 ml in Regimens II and III respectively, which was much less than in Regimen I (343.8 ml) (p values 0.05 and 0.01 respectively). Further, no patient receiving Regimen III had relapse of coagulation dysfunction. In severe envenomation, average dose of ASV required was almost similar in Regimens II and III, i.e., 213.7 ml and 233.7 ml respectively, as compared to 433.3 ml required in Regimen I (p values 0.02 and 0.001 respectively). However, time lapse for CT normalization was only 18 hours in Regimen III as compared to 23.6 hours and 24 hours in Regimens I and II respectively. CONCLUSION: Regimens consisting of continuous intravenous infusion of ASV i.e., Regimen II in mild envenomation and Regimen III in moderate and severe envenomation are likely to make significant saving of ASV and reduction of recurrence of coagulation dysfunction.

Defectos congénitos de antitrombina III y proteínas S y C durante el embarazo / Congenital defects of antithrombin III and proteins C and S during pregnancy: report of ten cases

We report 10 patients with congenital deficiencies of the natural anticoagulant proteins S, C and antithrombin III. Thirteen of a total of 30 pregnancies were managed at the perinatal branch of our department. We discuss the mechanism of action of these proteins and their role in thrombotic events. We analyze the most frequent thrombotic complications and we discuss the general guidelines for the investigation of a patient with a suspected congenital thrombophilia with special regard to its management during pregnancy, delivery and perinatal outcome

Disfibrinogenemia congénita como causa de AVE en la infancia / Congenital dysfibrinogenemia as a cause of stroke in infancy

La disfibrinogenemia congénita es una alteración del fibrinógeno que puede ser congénita o adquirida; en el primer caso es de trasmisión autosómica dominante pudiendo su déficit producir hemorragia o trombosis. Un caso excepcional de infarto hemorrágico gangliobasal secundario a esta etiología y su evolución clínica es analizado en este trabajo

Left ventricular assistance with the centrifugal pump: management of the patient with stunned myocardium

Existe un grupo de enfermos que no pueden separarse del aparato cardiopulmonar después de cirugía a cielo abierto aunque se utilize el balón intra-aóritco y/o agentes inotrópicos. Muchos de estos pacientes pueden recuperarse y prolongar su vida si se utiliza un mecanismo de asistencia al corazón izquierdo (Left Heart Assit Device-1VAD). Nuestro grupo utiliza la bomba centrífuga como mecanismo de asistencia. Para evitar que el paciente se deteriore se debe utilizar mecanismo de asistencia tan pronto se determine que el paciente no puede sostener su gasto cardíaco con el balón intra-aórtico solamente. Recomendamos la canulación del atrio izquierdo através de la vena pulmonar derecha superior. La aorta ascendente se canula como se hace rutinariamente y el flujo de la bomba se mantiene sobre un litro por minuto para evitar embolias, ya que preferimos no usar heparina. Concentrados de albumina se adminsitran para compensar con los cambios en flujo de fluídos que ocurren en el instersticio del paciente (tercer espacio). Para mantener una presión oncótica satisfactoria instalamos un hemoconcentrador al circuito. Como las cuagulopatías se observan frecuentemente, el esternón se deja abierto y esto nos permite la rápida exploración del mediastismo si el paciente pierde una cantidad excesiva de sangre. En el manejo de estos pacientes hay que usar farmacos para mantener la resistencia periférica baja y un nivel de presión sistémica adecuado para perfundir los órganos del cuerpo. La separación de los enfermos de el mecanismo de asistencia usualmente es un proceso gradual que toma entre dos y cuatro horas. Este artículo describe el manejo clínico de un enfermo completamente dependiente en la bomba centrífuga de asistencia del ventrículo izquierdo (LVAD)

Manejo da coagulopatia associada à morte fetal intraútero / Management of coagulopathy associated with intrauterine fetal death

Realizou-se uma revisäo bibliográfica visando atualizaçäo na fisiopatologia e terapêutica da coagulopatia associada à morte fetal intraútero, com enfoque principal na heparinoterapia