To examine anticoagulation management at the Bella Coola Medical Clinic in British Columbia.
Charts of all patients in the Bella Coola Valley receiving warfarin were assessed. Data were analyzed using Microsoft Excel.
Bella Coola Medical Clinic on the remote central coast of British Columbia.
Twenty-one patients at the Bella Coola Medical Clinic who were receiving warfarin.
All international normalized ratio (INR) tests over the preceding 12 months were examined for results, time elapsed since previous test, and interval until next scheduled test.
An in-range INR rate of 60% is considered acceptable for anticoagulation services. The clinic had performed 406 INR tests on these 21 patients over the last 12 months. We found that 53% of all INR results fell strictly within the recommended therapeutic range. The relative success of anticoagulation management in Bella Coola probably results from several factors. For instance, physicians usually responded to out-of-range INR results with close monitoring: in 71% of cases, follow-up tests were scheduled within 1 week. On average, patients attended 77% of these visits on schedule; 58% of all out-of-range INR results were followed up with retesting within 1 week.
Our results suggest that primary care physicians can manage anticoagulation adequately, even in remote settings.
Recombinant factor VIIa (rFVIIa; NovoSeven(R), Novo Nordisk, Bagsvaerd, Denmark) induces hemostasis in patients with severe hemophilia and inhibitors, and has been found to control hemorrhage associated with severe trauma and surgery in patients with basically normal hemostatic mechanisms from the start. By enhancing the generation of thrombin on activated platelets, rFVIIa facilitates the formation of a tight, stable fibrin plug that is resistant to premature lysis. Clinical efficacy has been achieved with doses of rFVIIa much lower than originally proposed by in vitro models. Based on early clinical experiences, a dosing schedule of 90 to 120 microg/kg every 2 hours for the first 24 hours was recommended for serious bleeds and surgical cover. This schedule has been shown to induce and maintain hemostasis in 83% to 95% of serious bleeding episodes, and in 90% to 100% of major surgical cases. However, "mega" doses of rFVIIa may demonstrate greater efficacy in the treatment of joint bleeds, as they are more likely to evoke a full thrombin burst. Interpatient variation in recovery rates, clearance rates, and the ability to generate thrombin on the activated platelet surface may influence the efficacy of rFVIIa. Optimal doses may thus vary not only between hemophilia patients, but also between patients treated for other bleeding disorders.
A 5-day-old newborn presented with neonatal enteroviral infection. The patient's hospital course was complicated by acute liver dysfunction, renal insufficiency, fluid overload, respiratory failure, hypertension, catheter related thrombosis, Klebsiella pneumoniae sepsis, intracerebral and intraventricular hemorrhage, and disseminated intravascular coagulation (DIC). Administration of fresh frozen plasma (FFP) and cryoprecipitate failed to control the patient's hemostasis and led to significant fluid overload. Recombinant activated factor VII (rFVIIa, Novoseven NovoNordisk, Bagsvaerd, Denmark) was given to the neonate as a bolus (rFVIIa at 60-80 microg/kg body weight), followed by a continuous infusion (2.5-16 microg/kg/hr). Recombinant activated factor VII controlled hemostasis, until the patient's liver function recovered. The patient's blood product requirement significantly decreased and his fluid overload resolved. Administration of rFVIIa appears to have stabilized the coagulation process. The patient appears to have fully recovered from the infection's complications.
Recombinant activated factor VII (rFVIIa, NovoSeven, Novo Nordisk A/S, Denmark) is a treatment used to prevent and arrest intra- and postoperative bleeds in patients with haemophilia A or B complicated by circulating anticoagulants (inhibitors of FVIII and FIX). Patients who qualify for liver transplantation may have varying degrees of coagulation impairment, which may adversely impact elective anaesthetic and surgical procedures and elevate the risk of intraoperative bleeds, which require massive blood transfusions and worsen prognosis. Recently, reports have been published on the use of rFVIIa prior to surgical procedures, which are likely to cause severe blood loss as well as for so-called emergency therapy of coagulation disorders during liver transplantation.
Chronometric hypocoagulation was observed in children, suffering an acute hematogenic ostheomyelitis, witnessed by processes of thrombin formation according to internal (the prolonged time of the blood plasm recalcification and activated partial thromboplastin time) and external (the thrombin time enhancement) ways of the blood coagulation process, as well as changes in fibrinogenesis mechanisms (the thrombin time prolongation). The lowering of anticoagulant capacity of the blood (the antithrombin III activity inhibition by 18.5%) was combined with significant increase of the thrombocytes functional activity (the rising of their adhesive and aggregational properties) in more than two times, which have occurred on the background of constant content of fibrinogen in the blood. Changes in the system of the plasm fibrinolysis in an acute hematogenic ostheomyelitis was characterized by inhibition of cofermental and, mainly, fermental fibrinolytic activity of the blood plasm, in conjunction with Hageman-dependent fibrinolysis intensification and was accompanied by accumulation of soluble complexes of fibrin-monomer in the blood. So far, chronometric hypocoagulation is secondary process, caused by the influence of soluble complexes of fibrin-monomer, which blocks fibrinogenesis. That's why the general potential of the blood coagulation system in children with an acute hematogenic ostheomyelitis must be regarded as a structural hypercoagulation.