According to a 2017 American College of Obstetricians and Gynecologists (ACOG) guidance document on postpartum hemorrhage, fibrinogen concentrates are specifically approved for treating acute bleeding in patients with congenital fibrinogen deficiency. Nevertheless, limited data are available regarding the use of prothrombin complex concentrates (PCCs) and fibrinogen concentrates in postpartum hemorrhage (PPH) and disseminated intravascular coagulation. Consequently, their use is advised only after several rounds of standard massive transfusion agents have been administered and in consultation with an expert in massive hemorrhage. The guidance does not provide recommendations for specific fibrinogen concentrate products, including Fibryga, or product-specific dosing for PPH following vaginal or cesarean delivery. [1] Several review articles have evaluated fibrinogen concentrate for PPH, with evidence suggesting that fibrinogen <200 mg/dL is associated with progression to severe P...

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The 2020 American College of Cardiology guidelines for management of bleeding during oral anticoagulation provide guidance on warfarin-related bleeding reversal using 4-factor prothrombin complex concentrate (4F-PCC) as a class and do not specifically mention Balfaxar. For vitamin K antagonist (VKA) reversal, 4F-PCC may be dosed using international normalized ratio (INR)-based weight-adjusted protocols or a fixed-dose approach of 1,000 units for non-intracranial major bleeding and 1,500 units for intracranial hemorrhage, with intravenous vitamin K co-administration. The guidelines do not provide fixed-dose prothrombin complex concentrate (PCC) protocols for direct oral anticoagulant-associated bleeding; instead, specific reversal agents are preferred, with PCC or activated PCC recommended as alternatives when targeted reversal agents (e.g., antidotes) are unavailable. [1] The 2025 Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) guidelines provide guidance ...

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According to a 2022 evidence-based dosing review from the Dutch Pediatric Formulary, intranasal (IN) dexmedetomidine 1 to 2 mcg/kg as a single dose before induction of anesthesia is recommended for premedication in pediatric patients aged 6 months to 18 years. The recommendation was developed from a risk-benefit assessment of available pediatric efficacy, safety, and pharmacokinetic evidence. For procedural sedation, experts recommend a higher IN dose of 2 to 3 mcg/kg/dose, which may be repeated if necessary, with a maximum total dose of 200 mcg. Notably, although the review establishes a 200-mcg maximum total dose for procedural sedation, it does not specify an absolute maximum dose for IN dexmedetomidine when used as preoperative premedication. [1] A 2017 systematic review and meta-analysis evaluated the efficacy and safety of intranasal dexmedetomidine for preoperative premedication in 1,190 pediatric patients across 13 randomized controlled trials. The included studies admini...

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The 2015 Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations consensus statement, published before more recent studies evaluating thyroid hormone therapy in organ donors, recommended considering thyroid replacement with T3 or T4 in hemodynamically unstable brain-dead donors or potential cardiac donors with a left ventricular ejection fraction <45%, either alone or as part of combination hormonal therapy. The guideline acknowledged conflicting clinical evidence and noted that thyroid abnormalities after brain death may represent sick euthyroid syndrome rather than true hypothyroidism; a commonly used IV T4 regimen reported in the guideline is a 20-mcg bolus followed by 10 mcg/hour. In contrast, the 2020 Canadian clinical practice guideline conditionally recommended against routine thyroid hormone supplementation in neurologically deceased potential donors based on low-certainty evidence, as randomized trials had not de...

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The 2014 European Medicines Agency (EMA) guidance recommends overlapping rivaroxaban with a vitamin K antagonist (VKA) during conversion to maintain continuous anticoagulation. Rivaroxaban and the VKA should be administered concurrently until the INR is ≥ 2.0. Standard initial VKA dosing should be used for the first 2 days of the transition, followed by INR-guided dose adjustment. Because rivaroxaban can influence the INR, INR testing should not be performed earlier than 24 hours after the previous rivaroxaban dose. [1] A 2016 guidance document on practical management of direct oral anticoagulants (DOACs) for venous thromboembolism emphasizes that transitions between anticoagulants can increase both thromboembolic and bleeding risk if therapeutic anticoagulation is interrupted. In the ROCKET AF and ARISTOTLE trials, an approximate 4-fold increase in stroke or bleeding was observed at study completion, which was attributed to gaps in anticoagulation during transition to warfarin a...

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