Emergency oral anticoagulant reversal: the relative efficacy of infusions of fresh frozen plasma and clotting factor concentrate on correction of the coagulopathy.

Haemorrhage, including intracranial bleeding, is a common, potentially lethal complication of warfarin therapy and rapid and complete reversal of anticoagulation may be life-saving. Fresh frozen plasma (FFP) and vitamin K are most frequently administered. Because of the variable content of vitamin K-dependent clotting factors in FFP, and the effects of dilution, the efficacy of this approach is open to doubt. We have therefore compared the effects of FFP and clotting factor concentrates on the INRs and clotting factor levels of orally anticoagulated subjects requiring rapid correction of their haemostatic defect. In many, the pre-treatment INR was considered to be dangerously above the target therapeutic range. In the 12 patients given FFP, the INR did not completely correct (range 1.6-3.8, mean 2.3) indicating an ongoing anticoagulated state in all. In contrast, the INR in 29 subjects given clotting factor concentrates was completely corrected in 28 (range 0.9-3.8, mean 1.3). Following treatment, marked differences were observed in clotting factor IX levels between the two groups. The median factor IX level was 19 u/dl (range 10-63) following FFP infusion and 68.5 u/dl (range 31-111) following concentrate. In FFP treated patients, poorer responses were also observed for each of the other vitamin K-dependent clotting factors but these were less marked than for factor IX, which was present in low concentrations in some batches of FFP. Thus, haemostatically effective levels of factor IX cannot be achieved, in most instances, by the conventional use of FFP in patients requiring reversal of their anticoagulant therapy. Clotting factor concentrates are the only effective option where complete and immediate correction of the coagulation defect is indicated in orally anticoagulated patients with life or limb-threatening haemorrhage.

An evaluation and improvement program for inpatient anticoagulant control.

To improve the management and therapeutic control of inpatients on anticoagulant drugs, combined prescription and monitoring charts have been developed for both heparin and warfarin which incorporate clinical guidelines. These have been introduced throughout a 700-bedded acute teaching hospital via a structured program of change management. We have demonstrated improvements in the quality of anticoagulant control (assessed with a custom-written computer program), adherence to clinical guidelines and quality of monitoring and prescribing of anticoagulants in inpatients. The percentage time spent under-anticoagulated with heparin (activated partial thromboplastin time ratio < 1.5) fell from 32.7% to 18.5% (p < 0.0001), whereas there was no change in percentage time over-anticoagulated (5.1% vs. 5.8%; p = ns). The percentage time spent under-anticoagulated with warfarin was unaltered (26.3% vs. 29.8%; p = ns) but the percentage time spent over-anticoagulated (International Normalised Ratio > 4.5) was halved from 5.4% to 2.7% (p < 0.001). We conclude that the introduction of the charts led to significant improvements in anticoagulant control.

Successful repair of a massive coronary arteriovenous fistula in a 68-year-old man.

Successful ligation of a massive coronary arteriovenous fistula in a 68-year-old-man is reported. The defect, which extended from the left coronary artery to the coronary sinus, had been diagnosed 17 years earlier. At the time of repair, the patient's age and fistula related complications made him a relatively high-risk operative candidate. In light of this case, operative approaches for repairing coronary arteriovenous fistulas are discussed.

Operating theatre lists--accidents waiting to happen?

Each year the Medical Defence Societies report cases where litigation has arisen due to errors in operating theatres. Incorrect details on operating lists increase the risk of such errors. The Medical Defence Societies, in conjunction with the nursing profession, have produced recommendations to reduce the risks of errors in operating theatres (1). The patient's full name and hospital number should be checked against the theatre list by the receiving nurse. Abbreviations should be avoided and operating lists should be altered as little as possible and never by telephone. Current practice in our hospital is that operating lists are typed by the consultant's secretary, using information drawn from handwritten lists submitted by junior doctors or from admission lists. Currently the final operating list is not routinely double-checked. The possibility that such a system could lead to potentially dangerous errors prompted an audit of operating lists for a one-month period, including all specialties at the Royal Hallamshire Hospital, Sheffield. The aim was to measure the incidence of errors, omissions and alterations in completed operating lists.

Unusual intramural gastric metastasis of recurrent epithelial ovarian carcinoma.

Epithelial ovarian carcinoma regularly metastasizes to peritoneal surfaces throughout the abdomen and pelvis. Gastrointestinal involvement is usually limited to seromuscular involvement of the small and large bowel and its mesentery. Gastrointestinal invasion is most often superficial, mesentery is shortened, and intestinal lumens are narrowed. Transmural invasion is less common, as is gastrointestinal hemorrhage. We present a case of life-threatening intralumenal gastric hemorrhage from an intramural gastric metastasis of epithelial ovarian carcinoma effectively palliated with a gastric resection. Intralumenal gastric metastasis represents an unusual trophism of recurrent epithelial ovarian carcinoma. Surgical intervention for life-threatening hemorrhage, while not curative, may provide effective palliation in the otherwise fully functional patient and thereby reducing the need for medical attention and the anxiety assigned to recurrent gastrointestinal hemorrhage. Palliative maneuvers for gastric metastasis may require a multidisciplinary approach.

Antibiotic-associated fulminant pseudomembranous colitis without toxic megacolon.

Presented is a middle-aged male who developed a fulminant case of antibiotic-associated pseudomembranous colitis characterized by leukocytosis, hypoalbuminemia, ascites, and anasarca without toxic megacolon. The patient responded slowly to medical therapy consisting of intravenous metronidazole, oral vancomycin, and parenteral nutrition. Subsequently, cholestyramine was administered. A review of the literature concerning similar cases of fulminant pseudomembranous colitis is presented.

Surgical complications in bridging to transplantation: the Thermo Cardiosystems LVAD.

Left ventricular assistance with a number of different devices has been used to successfully bridge patients to cardiac transplantation. Surgical complications or complications related to the device itself, however, may preclude transplantation or lead to death. We report our recent experience with the Thermo Cardiosystems model 14 "HeartMate" left ventricular assist device in 3 patients. The device was implanted for 15 to 95 days. Complications included mediastinitis and peritonitis associated with the device in place before transplantation, and colonic perforation, and a late diaphragmatic hernia after transplantation. Despite these and other minor complications, all 3 patients underwent successful cardiac transplantation. Mechanical support for the right ventricle was not necessary. The Thermo Cardiosystems left ventricular assist device provided excellent support in a range of physiological conditions with no mechanical malfunction despite the surgical complications.

Celiac artery aneurysms: case reports.

Two recent patients with celiac artery aneurysms focus attention on the relevant diagnosis and therapeutic alternatives that lead to a successful outcome in these patients. Awareness of the nonspecific symptoms associated with splanchnic arterial aneurysms combined with ultrasonography, computerized axial tomography, and arteriography lead to the appropriate diagnosis of a celiac artery aneurysm prior to rupture and exsanguinating hemorrhage. Aneurysm resection offers a definitive means of treatment. Selective use of revascularization techniques bolsters the surgical approach by preventing hepatic ischemia and serving as an additional source of visceral arterial blood flow. Our use of an autogenous or prosthetic graft from the intrarenal abdominal aorta proved to be a helpful adjunctive technique. Long-term vigilance is important because of the association of celiac artery aneurysms with other arterial occlusive and aneurysmal disease.

Anisoylated plasminogen streptokinase activator complex versus placebo. A preliminary multicentre study of safety and early mortality in acute myocardial infarction.

90 patients were enrolled into this preliminary multicentre study of the efficacy and safety of 30 units intravenous anisoylated plasminogen streptokinase activator complex (APSAC) compared with placebo in patients with acute myocardial infarction. 45 patients received APSAC and 45 placebo; the groups were similar for age, weight and site of infarction. There were significantly more women treated with APSAC (p less than 0.02). The mean time to treatment was 3.3 hours after symptoms of myocardial infarction for APSAC and 3 hours for placebo. The 30-day mortality was 7 patients in the placebo group and 1 in the APSAC group (p = 0.058). Adverse events were generally minor and were of similar overall frequency in both groups. There were more haemorrhagic events with APSAC, from which all patients recovered, and more cardiovascular events with placebo including 2 deaths from cardiogenic shock. APSAC showed a trend towards a reduction in 30-day mortality. Experience from this study has led to the initiation of the APSAC in myocardial infarction multicentre mortality study (AIMS).

Is cutaneous flushing prostaglandin mediated?

Intravenous administration of nicotinic acid (25 mg), resulted in a readily reproducible facial flush. The development of this flush was inhibited by two prostaglandin synthetase inhibitors, indomethacin and benorylate, but was not affected by the administration of the opiate receptor antagonist naloxone. Indomethacin, the agent with the greater anti-prostaglandin activity, was markedly more effective than benorylate in inhibiting the nicotinic-acid-induced rise in facial temperature. These findings will be useful in the in vivo assessment of the activity of prostaglandin inhibitors.