Managing patients in the perioperative setting receiving novel oral anticoagulation agents for thromboprophylaxis or stroke prevention with atrial fibrillation is an important consideration for clinicians. The novel oral anticoagulation agents include direct Factor Xa inhibitors rivaroxaban and apixaban, and the direct thrombin inhibitor dabigatran. In elective surgery, discontinuing their use is important, but renal function must also be considered because elimination is highly dependent on renal elimination. If bleeding occurs in patients who have received these agents, common principles of bleeding management as with any anticoagulant (including the known principles for warfarin) should be considered. This review summarizes the available data regarding the management of bleeding with novel oral anticoagulation agents. Hemodialysis is a therapeutic option for dabigatran-related bleeding, while in vitro studies showed that prothrombin complex concentrates are reported to be useful for rivaroxaban-related bleeding. Additional clinical studies are needed to determine the best method for reversal of the novel oral anticoagulation agents when bleeding occurs.

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Background: Critical illness is common in hematological malignancy (HM) patients. Advance care planning (ACP) can allow these patients to express their care preferences prior to life-threatening illnesses. The objective of this study was to evaluate physicians' perspectives surrounding ACP in HM patients. Methods:We administered a survey to intensivists and hematologic oncologists who care for patients with HM across Canada and the United Kingdom. Potential respondents were identified from institutions that have a hematologic oncology program. The survey was disseminated electronically.Results: 111 physicians completed the survey with a response rate of 19% (39% across those who opened the email); 52% of respondents were intensivists and 48% hematologic oncologists. 15.5% of physicians reported that ACP happens routinely at their institution, while 8.3% of physicians stated that code status is routinely discussed. ACP discussions were most commonly reported at the onset of critical illness (84.3% of respondents), during disease recurrence (52.9% of respondents), or during transition to a strictly palliative approach (54.9% of respondents). Commonly cited barriers to ACP centred on physicians' concern about the reaction of the patient or family. Conclusion:This study emphasizes the need for earlier and more frequent ACP discussions in this high-risk population with a variety of barriers identified.

A 45-year-old man with a history of systemic lupus erythematosus presented with progressive weakness and areflexia. Electromyogram revealed reduced motor and sensory amplitudes without demyelinating features. He was clinically diagnosed with the acute motor and sensory axonal neuropathy variant of Guillain-Barré syndrome. Despite intravenous immunoglobulin therapy, he deteriorated with loss of all voluntary motor function and cranial nerve reflexes. Concomitant investigations revealed class V lupus nephritis. Therapy was initiated with plasma exchange, glucocorticoids and further immunosuppression, with gradual neurological recovery. We present the first documented case of fulminant Guillain-Barré syndrome as a neuropsychiatric manifestation of systemic lupus erythematosus, highlighting how immune-mediated polyneuropathy via diffuse deafferentation may mimic the outward appearance of brain death. While glucocorticoids are not indicated in idiopathic Guillain-Barré, when this neurological disorder is a consequence of systemic lupus erythematosus, immunomodulatory treatment should be initiated to prevent neurological deterioration.