Arterial blood gas analysis is used to measure the pH and the partial pressures of oxygen and carbon dioxide in arterial blood. The investigation is relatively easy to perform and yields information that can guide the management of acute and chronic illnesses. This information indicates a patient's acid-base balance, the effectiveness of their gas exchange and the state of their ventilatory control. Interpretation of an arterial blood gas result should not be done without considering the clinical findings. The results change as the body compensates for the underlying problem. Factors relating to sampling technique, specimen processing and environment may also influence the results.
Warfarin and heparin are the traditional mainstay anticoagulant therapies for treating thromboembolic disease.
These drugs, with a documented history of utility, also have inherent difficulties in usage; in particular, the complicated monitoring and numerous drug–drug interactions of warfarin, and the need for parenteral administration of heparins.
New agents have recently emerged that target specific elements of the clotting pathway. Rivaroxaban, which inhibits activated factor X (Xa), is currently in clinical trials and is the most advanced factor Xa inhibitor.
The drug offers once‐daily oral dosing, with no need for injections, dose titration, or frequent blood tests to monitor the international normalised ratio. It has a rapid onset of action and, although there is no specific antidote, it has a short plasma elimination half‐life (about 5–9 hours).
Evidence from recently published large‐scale phase III clinical trials shows rivaroxaban to be superior to enoxaparin for prophylaxis of venous thromboembolism after major orthopaedic surgery.
Studies have shown rivaroxaban to have a sound safety profile, with an incidence of bleeding similar to enoxaparin in phase III clinical trials.
Few side effects and drug–drug interactions between rivaroxaban and common medications have been found thus far, although some interactions with potent cytochrome P450 3A4 inhibitors have been observed.
It is hoped that rivaroxaban may be used as a first‐line anticoagulant for prophylaxis of venous thromboembolic disease in postsurgical patients.
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Dabigatran etexilate was recently approved by the Therapeutic Goods Administration for thromboprophylactic use in adults undergoing elective total hip or knee replacement.
Dabigatran etexilate is the prodrug of the active moiety dabigatran, an orally active agent that could replace enoxaparin in some clinical indications.
Dabigatran is a direct thrombin inhibitor; it has stable, predictable pharmacokinetics and does not require routine monitoring.
Pooled efficacy data from large‐scale phase III clinical trials of dabigatran use in orthopaedic thromboprophylaxis have shown non‐inferiority to enoxaparin, with total venous thromboembolism results of 3.8% for dabigatran etexilate 150 mg and 3.0% for dabigatran etexilate 220 mg, compared with 3.3% for enoxaparin.
Pooled safety results for dabigatran are similar to those for enoxaparin, with major bleeding rates of 1.1% for dabigatran etexilate 150 mg and 1.4% for dabigatran etexilate 220 mg, compared with 1.4% for enoxaparin.
Dabigatran failed to demonstrate non‐inferiority compared with enoxaparin 30 mg twice daily for orthopaedic thromboprophylaxis.
Issues relating to the use of dabigatran include its lack of antidote, limited application in renal disease, and interaction with drugs such as amiodarone and verapamil.
Several trials investigating the use of dabigatran for other indications, such as stroke prevention in atrial fibrillation and acute coronary syndromes, are underway.
Given its safety profile, efficacy, oral bioavailability and stable pharmacokinetic properties, dabigatran may be a viable alternative to enoxaparin for thromboprophylaxis in orthopaedic surgery.
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