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Créteil, France

New direct oral anticoagulants (NOAC), inhibitors of factor IIa or Xa, are expected to be widely used for the treatment of venous thromboembolic disease, or in case of atrial fibrillation. Such anticoagulant treatments are known to be associated with haemorrhagic complications. Moreover, it is likely that such patients on long-term treatment with NOAC will be exposed to emergency surgery or invasive procedures. Due to the present lack of experience in such conditions, we cannot make recommendations, but only propose management for optimal safety as regards the risk of bleeding in such emergency conditions. In this article, only dabigatran and rivaroxaban were discussed. For emergency surgery at risk of bleeding, we propose to dose the plasmatic concentration of drug. Levels inferior or equal to 30. ng/mL for both dabigatran and rivaroxaban, should enable the realization of a high bleeding risk surgery. For higher concentration, it was proposed to postpone surgery by monitoring the evolution of the drug concentration. Action is then defined by the kind of NOAC and its concentration. If the dosage of the drug is not immediately available, proposals only based on the usual tests, PT and aPTT, also are presented. However, these tests do not really assess drug concentration or bleeding risk. In case of severe haemorrhage in a critical organ, it is proposed to reduce the effect of anticoagulant therapy using a nonspecific procoagulant drug (activated prothrombin concentrate, FEIBA, 30-50. U/kg, or non-activated 4-factors prothrombin concentrates 50. U/kg). For any other type of severe haemorrhage, the administration of such a procoagulant drug, potentially thrombogenic in these patients, will be discussed regarding concentration of NACO and possibilities for mechanical haemostasis. © 2013 Société française d'anesthésie et de réanimation (Sfar). Source

Dessap A.M.,Service de Reanimation medicale | Dessap A.M.,University Paris Est Creteil | Dessap A.M.,French Institute of Health and Medical Research | Deux J.-F.,Service dimagerie medicale | And 23 more authors.
American Journal of Respiratory and Critical Care Medicine | Year: 2011

Rationale: The pathophysiology of acute chest syndrome (ACS) in patients with sickle cell disease is complex, and pulmonary artery thrombosis (PT) may contribute to this complication. Objectives: To evaluate the prevalence of PT during ACS using multidetector computed tomography (MDCT). Methods: We screened 125 consecutive patients during 144 ACS episodes. One hundred twenty-one MDCTs (in 103 consecutive patients) were included in the study. Measurements and Main Results: Twenty MDCTs were positive for PT, determining a prevalence of 17% (95% confidence interval, 10-23%). Revised Geneva clinical probability score was similar between patients with PT and those without. D-dimer testing was very often positive (95%) during ACS. A precipitating factor for ACS was less frequently found in patients with PT as compared with those without. Patients with PT exhibited significantly higher platelet counts (517 [273-729] vs. 307 [228-412] 10 9/L, P < 0.01) and lower bilirubin (28 [19-43] vs. 44 [31-71] mmol/L, P < 0.01) levels at the onset of ACS as compared with others. In addition, patients with PT had a higher platelet count peak (537 [345-785] vs. 417 [330-555] 10 9/L, P = 0.048) and smaller bilirubin peak (36[18-51] vs. 46 [32-83] μmol/L, P = 0.048) and lactate dehydrogenase peak (357 [320-704] vs. 604 [442-788] IU/L, P = 0.01) during hospital stay as compared with others. Conclusions: PT is not a rare event in the context of ACS and seems more likely in patients with higher platelet counts and lower hemolytic rate during ACS. Patients with sickle cell disease presenting with respiratory symptoms suggestive of ACS may benefit from evaluation for PT. Source

Khetta M.,Service de Medecine Interne | Lemaitre C.,Service dHepato gastro enterologie | Lecam Duchez V.,Laboratoire dHemostase | Lecam Duchez V.,French Institute of Health and Medical Research | And 9 more authors.
Revue de Medecine Interne | Year: 2015

Introduction: Diagnosis of AL amyloidosis can be complicated by the diversity and the absence of specificity of symptoms. Case report: We report a patient who presented with a non-traumatic hepatic hematoma, leading to the discovery of hepatic amyloidosis secondary to probable multiple myeloma. The originality of our report lies in the discovery of two acquired abnormalities of haemostasis: a factorX deficiency and an acquired von Willebrand syndrome, by a likely inhibitor. Conclusion: Our case report is a reminder of the importance of haemostasis analysis in AL amyloidosis. © 2014 Société nationale française de médecine interne (SNFMI). Source

Schiettecatte S.,Center Hospitalier Of Cambrai | Staelen P.,Center Hospitalier Of Cambrai | Okiemy E.,Center Hospitalier Of Cambrai | Hajjar M.,Center Hospitalier Of Cambrai | And 3 more authors.
Journal de Pharmacie Clinique | Year: 2012

Heparin induced thrombocytopenia (HIT) is a rare but serious complication of heparin treatment. Its management is an emergency which requires the administration of an alternative anticoagulant therapy. We report the case of a 39-year-old man suffering from pathological obesity (236 kg) who developed HIT during a hospitalization for acute respiratory failure. The latter was early diagnosed. The pharmacist took actively part in the multidisciplinary meetings required by the patient's management. These concerned in particular the choice of the anticoagulant therapy which confronted danaparoïd sodium, the use of which is well documented, with argatroban, more recently available. We decided on argatroban which offered some pharmacokinetic and practical advantages in this case. However, no published data is yet available involving the use of this anticoagulant among obese people. At first, the treatment was controlled at a dose of 1 μg/kg/min (half dose). Imbalance of ACT (activated clotting time) then occurred and required some dosage adjustments by steps of 0,25 μg/kg/min. The pharmacist also intervened in care units to increase the awareness of nurses on the product's preparation and conservation terms. However, some infusion mistakes were committed, probably causing ACT variations. The clinical outcome was finally favourable, the patient's platelet count returning to normal values 10 days after the start of argatroban and him being discharged home without after effects. Source

Guignant C.,Laboratoire dImmunologie | Guignant C.,University of Lyon | Venet F.,Laboratoire dImmunologie | Venet F.,University of Lyon | And 12 more authors.
Intensive Care Medicine | Year: 2013

Purpose: A new pathway of three protein tyrosine kinase receptors, namely, the TAM receptor family [Tyro-3, Axl and Mer tyrosine kinase (MerTK)], has recently been described to negatively control immune responses. The objective of this prospective, observational, clinical study was to investigate the expression patterns of TAM receptors in circulating white blood cells collected from patients with septic shock. Methods: The expression of TAM receptors was measured by flow cytometry in circulating leukocytes from patients with septic shock sampled on days (D) 1-2 (n = 47) and D3-4 (n = 37) after the onset of shock, severe trauma patients at D1-2 after trauma (n = 51) and healthy individuals (n = 23). Results: On D1-2 after injury, MerTK was overexpressed in monocytes and neutrophils collected from patients with septic shock in comparison with those collected from healthy volunteers and trauma patients. This phenomenon was also observed for mRNA. Conversely, the expression of Tyro-3 and Axl was higher in monocytes from trauma patients versus healthy volunteers or those in septic shock. MerTK expression between D1-2 and D3-4 remained elevated in patients suffering from septic shock who died or developed an intensive care unit-acquired infection, whereas it decreased in patients who recovered uneventfully. This in vivo observed expression pattern was reproduced ex vivo after the incubation of healthy volunteer cells with plasma from septic shock or trauma patients. Conclusions: MerTK expression in circulating innate immune cells is increased in patients with septic shock in comparison with healthy volunteers and trauma patients. Persistent MerTK overexpression after septic shock is associated with adverse outcome. The role of this family of receptors in the pathophysiology of injury-induced immune dysfunctions deserves to be specifically investigated. © 2013 Springer-Verlag Berlin Heidelberg and ESICM. Source

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