Unclassified bleeding disorders: outcome of haemostatic challenges following tranexamic acid and/or desmopressin.

INTRODUCTION: In a minority of patients with a significant bleeding history no cause is found despite extensive testing and we diagnose such cases as unclassified bleeding disorders (UBD). UBDs may have diverse underlying causes and currently no standard management strategy exists in the event of a haemorrhage or to cover surgery. AIM: To document the clinical characteristics and response to treatment of UBDs. METHODS: We performed a retrospective chart review of all patients with UBDs who had an invasive procedure at our centre between 1998 and 2014. RESULTS: The commonest symptoms were menorrhagia (89%) and bleeding at the time of surgery (88%) or dental extraction (85%). A total of 33 patients underwent 78 minor and major haemostatic challenges. Haemostatic cover was provided in 28 procedures with tranexamic acid alone, two with desmopressin and 45 with both agents in combination. A successful haemostatic outcome was observed in 70/78 (90%) cases. No patient required additional surgical intervention to achieve haemostasis, but one patient required a platelet transfusion to control postoperative bleeding. CONCLUSIONS: This is the first study to report on the investigation and treatment of UBD. Future studies are needed to further our understanding of the bleeding phenotype and identify any underlying causes.

Measurement of blood loss during postpartum haemorrhage.

BACKGROUND: We set out to validate the accuracy of gravimetric quantification of blood loss during simulated major postpartum haemorrhage and to evaluate the technique in a consecutive cohort of women experiencing major postpartum haemorrhage. The study took part in a large UK delivery suite over a one-year period. All women who experienced major postpartum haemorrhage were eligible for inclusion. METHODS: For the validation exercise, in a simulated postpartum haemorrhage scenario using known volumes of artificial blood, the accuracy of gravimetric measurement was compared with visual estimation made by delivery suite staff. In the clinical observation study, the blood volume lost during postpartum haemorrhage was measured gravimetrically according to our routine institutional protocol and was correlated with fall in haemoglobin. The main outcome measure was the accuracy of gravimetric measurement of blood loss. RESULTS: Validation exercise: the mean percentage error of gravimetrically measured blood volume was 4.0±2.7% compared to visually estimated blood volume with a mean percentage error of 34.7±32.1%. Clinical observation study: 356 out of 6187 deliveries were identified as having major postpartum haemorrhage. The correlation coefficient between measured blood loss and corrected fall in haemoglobin for all patients was 0.77; correlation was stronger (0.80) for postpartum haemorrhage >1500mL, and similar during routine and out-of-hours working. CONCLUSION: The accuracy of the gravimetric method was confirmed in simulated postpartum haemorrhage. The clinical study shows that gravimetric measurement of blood loss is correlated with the fall in haemoglobin in postpartum haemorrhage where blood loss exceeds 1500mL. The method is simple to perform, requires only basic equipment, and can be taught and used by all maternity services during major postpartum haemorrhage.

The use of intravenous iron in patients with cancer-related anaemia.

Intravenous iron has become the standard of care in patients with renal failure receiving treatment with erythropoiesis stimulating agents (ESAs) to treat true and functional iron deficiency and to prevent its development in haemodialysis patients. In cancer-related anaemia, several recently published, randomised studies suggested that intravenous iron improved haemoglobin response rates in ESA-treated patients compared to those treated with oral iron or placebo. The data supporting the efficacy of intravenous iron instead of oral iron in this setting are increasingly persuasive but larger randomised trials are needed before definitive recommendations are made.

Lower limb contrast venography: a modified technique for use in thromboprophylaxis clinical trials for the accurate evaluation of deep vein thrombosis.

Lower limb venography remains the imaging modality of choice for detection of asymptomatic deep vein thrombosis (DVT) in clinical trials of anticoagulant agents. A variety of techniques of venography have been described. Here, we describe a modified technique (the "King's" technique) developed to increase the overall adequacy of identification of lower limb veins and detection of small asymptomatic DVT. Essential elements include proper preparation of patients prior to their arrival in the radiology department, intermittent use of tourniquets to ensure complete and adequate deep vein filling, use of a consistent image acquisition sequence and visualization of all veins in at least two different planes. Use of this technique minimizes technical difficulties, provides improved patient through-put in "busy" fluoroscopy units and, ultimately, improves "off-site" levels of adjudication.

Fatal pulmonary embolism in hospitalised patients: a necropsy review.

AIMS: To carry out a retrospective review of all postmortem reports during the period 1991 to 2000 at King's College Hospital, London, as an extension of a previous analysis performed for the period 1965 to 1990. METHODS: The number of deaths resulting from necropsy confirmed fatal pulmonary embolism in hospitalised patients was determined, and a limited analysis of the clinical characteristics of those patients who died was performed. RESULTS: During the 10 year period, 16 104 deaths occurred and 6833 (42.4%) necropsies were performed. The outcome measure, fatal pulmonary embolism, was recorded as cause of death in 265 cases (3.9% of all necropsies; 5.2% of adult cases). No deaths from pulmonary embolism occurred in patients under 18 years of age; 80.0% occurred in patients older than 60 years. Of the fatal emboli, 214 of 265 (80.8%) occurred in patients who had not undergone recent surgery. Of these patients, 110 (51.4%) had suffered an acute medical illness in the six weeks before death, most often an acute infectious episode (26 cases). CONCLUSIONS: Thromboembolic events remain a relatively common cause of death in hospitalised patients and appear to occur more frequently in non-surgical than in surgical patients.

Prophylaxis of venous thromboembolism in medical patients.

Prophylaxis of venous thromboembolism in medical patients is an area where the potential benefits to patients are great. Venous thromboembolism is at least as common among medical as it is among surgical patients. Despite the widespread use of thromboprophylaxis in surgical patients, fatal pulmonary embolism is one of the most common causes of preventable death in the hospital. This may result from underuse of thromboprophylaxis in medical patients. The incidence of venous thromboembolism varies, but a history of previous venous thromboembolism, age 40 years and older, immobility, and specific illnesses such as stroke, myocardial infarction, heart failure, and cancer put patients at particular risk. Most early studies assessed the use of anticoagulants such as unfractionated heparin, low-molecular-weight heparin, and warfarin at reducing the incidence of venous thromboembolism in surgical patients. More recent studies and those currently being carried out are assessing the role of thromboprophylaxis in general medical patients and those with specific medical illnesses. As the evidence accumulates and guidelines are strengthened physicians will be able to tailor the use of thromboprophylaxis to the individual patient's needs.

Benefits of deep-vein thrombosis prophylaxis in the nonsurgical patient: The MEDENOX trial.

Venous thromboembolism (VTE) is a common complication of hospitalized patients, imposing a major clinical and economic burden. Three of four cases of fatal pulmonary embolism occur in nonsurgical settings, but thromboprophylaxis is far less common in medical than in surgical patients. This is mainly attributable to the heterogeneity of nonsurgical populations and lack of high-quality evidence to support specific thromboprophylactic measures. The recent Prophylaxis of Venous Thromboembolism in MEDical Patients With ENOXaparin (MEDENOX) trial addressed this deficiency by assessing the need for and the benefit:risk ratio of thromboprophylaxis in a well-defined group of medical patients immobilized with severe illness. The MEDENOX study showed that these patients are at significant risk of VTE. Enoxaparin, 40 mg once daily for 6 to 14 days, reduced the risk of VTE by 63% without increasing adverse events. It is anticipated that data from the MEDENOX study will be incorporated into future consensus guidelines on the prevention of VTE. Further studies are required to assess the benefit:risk ratio of therapy in other clearly-defined medical groups.