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Recombinant activated factor VII (rFVIIa) is indicated in bleeding patients when a life-threatening haemorrhage occurs. Prothrombin complex concentrates (PCCs) are also used for this indication in several countries, without any evidence-based rationale. Our objective was to compare the efficacy and safety of PCC and rFVIIa in a model of bleeding and thrombosis in haemodiluted rabbits.Forty-eight rabbits were randomly allocated into four groups: a control group and three treatment groups, in which animals were haemodiluted with hydroxyethyl starch 130/0.4 then administered either placebo, 160 µg kg(-1) rFVIIa, or 25 IU FIX kg(-1) PCC. The primary endpoint was hepatosplenic (HS) blood loss. Secondary endpoints were: (i) ear immersion bleeding time (IBT); (ii) thrombosis risk assessed by cyclic flow reductions (CFRs) of the carotid artery; and (iii) activated partial thromboplastin time (aPTT), and progress of thrombin activity.Haemodilution increased HS blood loss by 80% from 8 g (5-16) (control group) to 14 g (8-45) (placebo group) (P0.01). HS blood loss was not different in animals receiving either rFVIIa [10 g (7-22)] or PCC [15 g (4-33)] (P0.05) compared with the placebo group. Ear IBT was reduced with both rFVIIa and PCC. CFRs disappeared after haemodilution and were not restored with any treatment. Although PCC nearly doubled the total amount of thrombin generated, no significant change in the total amount of thrombin was seen in animals treated with rFVIIa.Neither rVIIa nor PCC reduced HS blood loss, whereas they both controlled the bleeding time, without increasing the thrombosis risk.

Background Patients receiving anti-platelet agents for secondary cardiovascular prevention frequently require non-cardiac surgery. A substantial proportion of these patients have their anti-platelet drug discontinued before operation; however, there is uncertainty about the impact of this practice. The aim of this study was to compare the effect of maintenance or interruption of aspirin before surgery, in terms of major thrombotic and bleeding events. Methods Patients treated with anti-platelet agents for secondary prevention and undergoing intermediate- or high-risk non-cardiac surgery were included in this multicentre, randomized, placebo-controlled, trial. We substituted non-aspirin anti-platelets with aspirin (75 mg daily) or placebo starting 10 days before surgery. The primary outcome was a composite score evaluating both major thrombotic and bleeding adverse events occurring within the first 30 postoperative days weighted by their severity (weights were established a priori using a Delphi consensus process). Analyses followed the intention-to-treat principle. Results We randomized 291 patients (n=145, aspirin group, and n=146, placebo group). The most frequent surgical procedures were orthopaedic surgery (52.2%), abdominal surgery (20.6%), and urologic surgery (15.5%). No significant difference was observed neither in the primary outcome score [mean values (sd)=0.67 (2.05) in the aspirin group vs 0.65 (2.04) in the placebo group, P=0.94] nor at day 30 in the number of major complications between groups. Conclusions In these at-risk patients undergoing elective non-cardiac surgery, we did not find any difference in terms of occurrence of major thrombotic or bleeding events between preoperative maintenance or interruption of aspirin. ClinicalTrials.gov identifier. NCT00190307.

The benefit/risk ratio of administering heparin during spinal anaesthesia in patients undergoing total hip replacement (THR) has not been studied widely. We conducted a prospective, randomized, double-blind study to compare low molecular weight heparin (LMWH) for 10 days and placebo in patients undergoing THR performed under spinal anaesthesia associated with gradual compression stockings. Efficacy was assessed by systematic bilateral ascending venography on day 10 +/- 2 in a sequential analysis. Among the 170 patients enrolled, data were available in 153 patients. In the LMWH group (n = 78) the total incidence of deep vein thrombosis (DVT) was 14.1% compared with 37.3% in the placebo group (n = 75) (P = 0.0016). No gross neurological sequelae were observed during the study. This study showed that the addition of LMWH in patients undergoing THR under spinal anaesthesia and wearing gradual compression stockings significantly decreased the incidence of venogram-proved DVT.

To avoid postoperative residual neuromuscular block there is a need for a change in clinician's attitude towards monitoring and reversal. This study aims to evaluate changes of perioperative neuromuscular block management during the last decade in our institution and to quantify the incidence of postoperative residual neuromuscular block.Patients receiving intermediate-acting neuromuscular blocking agents for scheduled surgical procedures during 3-month periods in 1995 (n=435), 2000 (n=130), 2002 (n=101), and in 2004 (n=218) were prospectively and successively enrolled in our study. The management of neuromuscular block in the operating room and the adequacy of the recovery were at the discretion of the anaesthesiologist. An attempt was made between each study period to promote a change in the management of neuromuscular block. In the post-anaesthesia care unit, train-of-four (TOF) stimulations were used to assess the presence of a residual neuromuscular block.Between 1995 and 2004 quantitative measurement and reversal of neuromuscular block in the operating room increased from 2 to 60% and from 6 to 42%, respectively (P0.001). During the same time, the incidence of residual neuromuscular block defined as a TOF ratio less than 0.9 decreased from 62 to 3% (P0.001). Use of objective neuromuscular monitoring and/or anticholinesterase drugs was less likely in patients with an inadequate recovery (P0.001).During the last decade the incidence of residual neuromuscular block strongly decreased in our institution. It confirms the positive impact of neuromuscular monitoring and reversal of neuromuscular block in routine anaesthetic practice.

Reports about anaphylactic and anaphylactoid reactions to rocuronium have increased recently. We report two new cases of documented grade III anaphylaxis, leading to death in one patient. The first case occurred in an 81-year-old ASA II woman scheduled for emergency abdominal surgery. Severe hypotension and tachycardia were observed after rocuronium, without bronchospasm. Neosynephrine allowed rapid resuscitation, and the patient recovered fully. The second patient was a 64-year-old ASA II man scheduled for abdominal surgery. Severe haemodynamic instability and bronchospasm occurred after rocuronium. Despite immediate life support, the postoperative period was complicated by persistent low systolic pressure, acute respiratory distress syndrome, acute renal failure, disseminated intravascular coagulation and pancreatitis, leading to the death of the patient.

We have investigated residual block after anaesthesia which included the use of the neuromuscular blocking agent vecuronium but no anticholinesterase, in 568 consecutive patients on admission to the recovery room. The ulnar nerve was stimulated submaximally using TOF stimulation (30 mA). Postoperative residual curarization was defined as a TOF ratio0.7. Of the 568 patients, 239 (42%) had a TOF0.7 in the recovery room. These patients had received a larger cumulative dose of vecuronium than patients who had full recovery (mean 7.7 (SD 3.6) mg vs 6.2 (2.7) mg; P0.05) and a shorter time had elapsed since the last vecuronium dose (117 (70) min vs 131 (80) min; P0.05). Of 435 patients whose trachea was extubated, 145 (33%) exhibited inadequate recovery from neuromuscular block. Six of these had one or no response to TOF stimulation and were reintubated. In the remaining 139 patients, neuromuscular block was successfully antagonized. Only 20 patients (3.5%) remembered TOF stimulation when questioned 2 h later in the recovery room, and discomfort associated with it was assessed using a visual analogue scale before discharge. We conclude that it is necessary to antagonize residual block produced by vecuronium.