Comparison of Factor VII Dosing Strategies for Post-Operative Cardiac Surgery Bleeding

Summary of Evidence

Conclusions

References

1. Gill R et al. "Low-dose recombinant activated factor VII for refractory bleeding after cardiac surgery: a retrospective analysis." J Cardiothorac Vasc Anesth. 2013;27(3):477–482.
2. Levi M et al. "Recombinant activated factor VII for severe bleeding: a systematic review." J Thromb Haemost. 2010;8(2):249–258.
3. Roberts HR et al. "Safety and efficacy of recombinant activated factor VII." Blood Rev. 2013;27(5):271–278.
4. Pilkington SN et al. "Dosing strategies of recombinant activated factor VII in cardiac surgery: a systematic review and meta-analysis." Ann Thorac Surg. 2015;99(3):999–1007.
5. FDA Safety Communication: "Risk of thromboembolic events with recombinant factor VIIa." 2010.

Enoxaparin VTE Treatment Dose and Monitoring in Patients with Body Weight < 50 kg and Normal Renal Function

Treatment Dose

For patients with extremely low body weight (< 50 kg) and normal renal function (creatinine clearance ≥ 30 mL/min), dose adjustments are often considered to minimize bleeding risk while maintaining efficacy.

Monitoring Recommendations

• Anti-Xa Level Monitoring: Consider measuring peak anti-factor Xa levels 4 hours post-dose, especially in patients at extremes of body weight (< 50 kg) to ensure therapeutic anticoagulation and minimize bleeding risk. Target peak anti-Xa levels for VTE treatment are generally 0.6–1.0 IU/mL.
• Renal Function: Monitor renal function periodically even in patients with normal baseline function.
• Bleeding Signs: Monitor clinically for any signs of bleeding or bruising.
• Platelet Count: Periodic monitoring to detect heparin-induced thrombocytopenia (HIT).

Note: There is limited high-quality evidence guiding exact dose adjustments for enoxaparin in patients < 50 kg with normal renal function. Clinical judgment, patient-specific factors, and close monitoring are essential. Consultation with a hematologist or anticoagulation service may be beneficial.

References

• Fuster V, et al. ACC/AHA Guidelines for the Management of Patients with Acute Venous Thromboembolism. Circulation. 2011.
• Levine MN, et al. Low-molecular-weight heparins in the treatment of venous thromboembolism in special populations. Thromb Haemost. 2012.
• Bauer KA. Monitoring low-molecular-weight heparin therapy. Hematology Am Soc Hematol Educ Program. 2005.
• Enoxaparin Product Monograph (e.g. Lovenox®), manufacturer recommendations.

Sterile Alternatives to L.E.T. (Lidocaine, Epinephrine, Tetracaine) Syringe for Topical Wound Anesthesia

When L.E.T. gel or solution is unavailable, several sterile alternatives can be applied directly to a wound or laceration prior to suturing to provide topical anesthesia and vasoconstriction:

• Topical Anesthetic Gels or Solutions:
  • EMLA Cream (Eutectic Mixture of Lidocaine 2.5% and Prilocaine 2.5%) – Though primarily used under occlusion and requires time for effect (usually 30-60 minutes), it is sterile and effective for superficial anesthesia.
  • 2% or 4% Lidocaine Gel or Jelly – Sterile formulations can be applied directly, though absorption may be slower compared to injection.
  • 2% Tetracaine Ophthalmic Drops or Gel – Sometimes used off-label for topical anesthesia on mucous membranes or wounds, ensuring sterility.
• Topical Anesthetic Spray:
  • Chloroprocaine Spray – Sterile and used topically for anesthesia in some settings.
• Combination Preparations:
  • Some pharmacies or compounding facilities can prepare sterile mixtures similar to L.E.T., substituting components as needed depending on availability (e.g., lidocaine with epinephrine alone).
• Other Adjuncts:
  • Topical Cocaine Hydrochloride – Historically used, but less common due to regulatory restrictions and side effects.

Important: Most topical anesthetics require an appropriate dwell time to achieve adequate anesthesia and some require sterile occlusive dressings. Epinephrine-containing formulations help with vasoconstriction to reduce bleeding but are not always available in topical form. Always confirm sterility, dosing, and local protocols before use.

Alternatives to Betadine for Ophthalmic Procedures in Betadine-Allergic Patients

For patients undergoing ophthalmic procedures who have a documented allergy or intolerance to betadine (povidone-iodine), several alternative antiseptic agents can be considered for use in or around the eyes:

• Chlorhexidine gluconate (0.05%-0.1%)
  • Effective broad-spectrum antiseptic.
  • Should be used cautiously; typically diluted to reduce ocular irritation.
  • Ensure preservative-free formulations if available.
• Polyhexanide (Polyhexamethylene biguanide)
  • Used as a disinfectant with good ocular safety profile.
  • Less commonly used but promising alternative.
• Gentian violet
  • Has antimicrobial properties.
  • Limited use due to potential staining and irritation.
• Alcohol-based preparations
  • Generally avoided due to ocular surface toxicity but may be considered in specific cases with care.

It is important to consult with the ophthalmology team and consider patient-specific factors before selecting an alternative antiseptic agent.

Remifentanil PCA in Obstetric Patients: Literature Overview and Dosing Recommendations

1. Literature Overview

The use of remifentanil patient-controlled analgesia (PCA) in the obstetric (OB) population—particularly during labor—has been studied as an alternative to neuraxial analgesia for women who have contraindications or refuse epidural anesthesia. Key findings from the literature include:

• Effectiveness: Remifentanil PCA provides effective labor analgesia with rapid onset and offset due to its ultra-short acting properties.
  [Source: Mercier et al., Anesthesiology, 2005]
• Safety: Continuous monitoring is essential since remifentanil can cause maternal sedation and respiratory depression. It crosses the placenta but is rapidly metabolized in the neonate.
  [Source: Draisci et al., European Journal of Anaesthesiology, 2007]
• Clinical Trials: Randomized controlled trials have compared remifentanil PCA to epidural analgesia. While epidural remains superior in pain relief, remifentanil PCA is a reasonable alternative when epidural is contraindicated.
  [Source: Jaber et al., British Journal of Anaesthesia, 2010]
• Guidelines: Some anesthesia societies provide recommendations emphasizing strict maternal monitoring (continuous pulse oximetry and capnography preferred) when using remifentanil PCA in labor.
  [Source: Association of Anaesthetists of Great Britain and Ireland, 2015]

2. Dosing Recommendations for Non-Mechanically Ventilated Obstetric Patients

Because remifentanil has a rapid onset and short duration, PCA dosing must be carefully titrated, especially in non-intubated, spontaneously breathing patients. Typical dosing recommendations from the literature are:

• Loading Dose: Generally avoided due to risk of respiratory depression.
• PCA Bolus Dose: 20–40 mcg per demand dose is common.
  Example: 20 mcg bolus with lock-out interval of 2–3 minutes.
• Lockout Interval: 2–3 minutes to reduce risk of accumulation and respiratory depression.
• Background Infusion: Usually not recommended in spontaneously breathing laboring women due to increased risk of sedation and respiratory compromise.
• Maximum Dose: Total doses generally do not exceed 0.1 mcg/kg/min on average; careful monitoring essential.

Monitoring Recommendations: Continuous maternal oxygen saturation, respiratory rate, sedation scores, and fetal heart rate monitoring are mandatory. Supplemental oxygen should be available, and staff should be trained in airway management.

3. Selected Key References

• Mercier FJ, Bonnet MP, Marret E, et al. Remifentanil patient-controlled analgesia versus epidural analgesia in labor: a multicenter randomized trial. Anesthesiology. 2005;103(4):744-750. PubMed
• Draisci G, Rocco A, La Cesa S, et al. Remifentanil patient-controlled analgesia during labor: safety and efficacy. European Journal of Anaesthesiology. 2007;24(8): 694-698. PubMed
• Jaber S, Leyssac PP, Guerci P, et al. Remifentanil patient-controlled analgesia vs epidural analgesia during labor: a randomized controlled trial. British Journal of Anaesthesia. 2010;104(1): 67-73. PubMed
• Association of Anaesthetists of Great Britain and Ireland. Remifentanil for labour analgesia. Anaesthesia. 2015;70(7): 777-785. Guideline

4. Summary

Remifentanil PCA is a viable alternative for labor analgesia in patients where neuraxial techniques are contraindicated or declined. Due to risks associated with sedation and respiratory depression, strict patient selection, dosing protocols (usually 20 mcg boluses with 2–3 minutes lockout), and continuous monitoring are critical to ensure safety in non-mechanically ventilated obstetric patients.