Prothrombin complex concentrate versus plasma for coagulopathy and bleeding after cardiopulmonary bypass (September 2022)
Unactivated prothrombin complex concentrate (PCC) is used to rapidly correct warfarin anticoagulation. Observational studies have described off-label use of PCC to treat surgical coagulopathic bleeding, but supporting data are limited. One randomized trial compared administration of PCC 15 IU/kg with fresh frozen plasma (FFP) 10 to 15 mL/kg in 100 patients who had excessive microvascular bleeding with prothrombin time (PT) >16.6 seconds and international normalized ratio (INR) >1.6 after cardiac surgery with cardiopulmonary bypass. Overall efficacy and safety were comparable between PCC and FFP, and patients receiving PCC had improved correction of PT and INR. Before considering administration of PCC or FFP, we treat other causes of intractable bleeding (e.g., surgical sources, thrombocytopenia, low fibrinogen levels, platelet dysfunction).
Risk factors for mortality after major surgery in older adults (October 2022)
Multiple factors contribute to the increased perioperative risk associated with older age. In a prospective study of nearly 1,200 major surgeries among community-living older adults (mean age 79 years), one-year mortality was higher in those with frailty (28 versus 6 percent) or probable dementia (33 versus 12 percent), and those requiring urgent surgery (22 versus 7 percent). These findings support other evidence suggesting that absolute age alone has only a modest impact on postoperative outcomes and should not be used as a sole criterion to guide decisions regarding patient selection for a major procedure.
Blood pressure and oxygen targets following sudden cardiac arrest (September 2022)
Supporting data to guide specific blood pressure and oxygen targets after sudden cardiac arrest (SCA) are limited, and practice is variable. In a recent open-label, two-by-two factorial trial, 789 patients with SCA were randomly assigned to a high versus low mean arterial pressure (MAP) target (77 versus 63 mmHg) as well as a restrictive versus liberal arterial oxygen tension (PaO2) target (68 to 75 versus 98 to 105 mmHg). At 90 days, rates of death or severe disability/coma at discharge were similar across all groups. Although the trial had limitations and confidence intervals were wide, these results do not support aggressive MAP goals or overly restrictive oxygenation in the care of patients after cardiac arrest, pending future studies.
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