Rapid reversal of coagulopathy in warfarin-related intracranial haemorrhages with prothrombin complex concentrates.

We report our initial experience using Profilnine SD, a 3-Factor prothrombin complex concentrate (PCC) in combination with fresh frozen plasma and vitamin K in seven patients admitted to our neurointensive care unit with oral anticoagulation therapy-related intracranial haemorrhage over a six-month period, to achieve rapid normalisation of the international normalised ratio (INR) and allow surgical evacuation when indicated. Four patients presented with subdural haematomas while three had intracerebral haematomas. Six of seven patients had admission INR in the appropriate therapeutic range for oral anticoagulation therapy. The median dose of PCC administered was 28.5 IU/kg body weight (interquartile range 21.3 to 38.5 IU/kg). All four patients with subdural haematoma underwent surgical evacuation once INR was less than 1.5. Median time from computed tomography diagnosis to surgery was 275 minutes (range 102 to 420 minutes). The median time to INR normalisation post-PCC administration was shorter, at 85 minutes (range 50 to 420 minutes) for the four patients who survived, versus 10 hours (range 9 to 44 hours) in the three patients who died. Two of the three patients who died had haematoma increase, worsening midline shift and subfalcine herniation, leading to withdrawal of therapy. Prothrombin complex concentrates should be considered for use in the urgent reversal of INR in oral anticoagulation therapy-related intracranial haemorrhage, potentially halting haematoma expansion and expediting urgent neurosurgical intervention, although data from randomised controlled trials is still lacking. The literature supporting the use of PCC is reviewed and a protocolised emergent treatment algorithm is proposed, which may help achieve earlier consistent normalisation of the INR.

The role of preoperative cervical spine X-rays in rheumatoid arthritis.

The cervical spine is frequently involved in rheumatoid arthritis and yet there exists no consensus on the need to screen for cervical spine subluxations preoperatively. We reviewed retrospectively 77 patients who underwent 132 operations under general or regional anaesthesia over a 44-month period. We found that while the majority of patients had received preoperative X-ray screening for cervical spine instability, a third of the X-ray examinations done had been inadequate. Many anaesthetists did not repeat cervical spine X-rays if there were previously performed views available. We showed that a complete X-ray examination of the cervical spine should include flexion and extension stress views in addition to frontal views of the odontoid and entire cervical spine. Anterior atlantoaxial subluxation was the most common subluxation encountered in our study population. The detection of cervical spine instability was found to significantly affect anaesthetic management, favouring techniques that avoided unprotected manipulations of the neck under anaesthesia.

Laryngeal mask insertion following inhalational induction in children: a comparison between halothane and sevoflurane.

The aim of this study was to compare laryngeal mask insertion conditions following inhalational induction with either halothane or sevoflurane. Fifty-eight healthy children scheduled for dental extraction were randomly assigned to receive nitrous oxide 66% in oxygen and 3.0 MAC of either halothane or sevoflurane introduced in a stepwise fashion. The laryngeal masks were inserted when an adequate depth of anaesthesia was attained and the reactions and time to insertion noted. Inhalational induction was smooth in both halothane and sevoflurane groups. Induction time and time to laryngeal mask insertion were significantly faster with sevoflurane. The conditions for laryngeal mask insertion were generally good with 86.2% and 89.2% in the halothane and sevoflurane groups respectively having had no reactions to insertion. The complications to laryngeal mask insertion encountered were mild. The emergence time from the anaesthetic was found to be shorter for sevoflurane but the difference was not statistically significant.