51
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Bradbury JL, Thomas SG, Sorg NR, Mjaess N, Berquist MR, Brenner TJ, Langford JH, Marsee MK, Moody AN, Bunch CM, Sing SR, Al-Fadhl MD, Salamah Q, Saleh T, Patel NB, Shaikh KA, Smith SM, Langheinrich WS, Fulkerson DH, Sixta S. Viscoelastic Testing and Coagulopathy of Traumatic Brain Injury. J Clin Med 2021; 10:jcm10215039. [PMID: 34768556 PMCID: PMC8584585 DOI: 10.3390/jcm10215039] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/24/2021] [Accepted: 10/27/2021] [Indexed: 12/14/2022] Open
Abstract
A unique coagulopathy often manifests following traumatic brain injury, leading the clinician down a difficult decision path on appropriate prophylaxis and therapy. Conventional coagulation assays—such as prothrombin time, partial thromboplastin time, and international normalized ratio—have historically been utilized to assess hemostasis and guide treatment following traumatic brain injury. However, these plasma-based assays alone often lack the sensitivity to diagnose and adequately treat coagulopathy associated with traumatic brain injury. Here, we review the whole blood coagulation assays termed viscoelastic tests and their use in traumatic brain injury. Modified viscoelastic tests with platelet function assays have helped elucidate the underlying pathophysiology and guide clinical decisions in a goal-directed fashion. Platelet dysfunction appears to underlie most coagulopathies in this patient population, particularly at the adenosine diphosphate and/or arachidonic acid receptors. Future research will focus not only on the utility of viscoelastic tests in diagnosing coagulopathy in traumatic brain injury, but also on better defining the use of these tests as evidence-based and/or precision-based tools to improve patient outcomes.
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Affiliation(s)
- Jamie L. Bradbury
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Scott G. Thomas
- Department of Trauma Surgery, Memorial Hospital, South Bend, IN 46601, USA;
| | - Nikki R. Sorg
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Nicolas Mjaess
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Margaret R. Berquist
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Toby J. Brenner
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Jack H. Langford
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Mathew K. Marsee
- Department of Otolaryngology, Portsmouth Naval Medical Center, Portsmouth, VA 23708, USA;
| | - Ashton N. Moody
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Connor M. Bunch
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
- Correspondence:
| | - Sandeep R. Sing
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Mahmoud D. Al-Fadhl
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Qussai Salamah
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Tarek Saleh
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Neal B. Patel
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Kashif A. Shaikh
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Stephen M. Smith
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Walter S. Langheinrich
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Daniel H. Fulkerson
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Sherry Sixta
- Department of Trauma Surgery, Envision Physician Services, Plano, TX 75093, USA;
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52
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Saidykhan J, Selevic L, Cinti S, May JE, Killard AJ. Paper-Based Lateral Flow Device for the Sustainable Measurement of Human Plasma Fibrinogen in Low-Resource Settings. Anal Chem 2021; 93:14007-14013. [PMID: 34615344 PMCID: PMC8529579 DOI: 10.1021/acs.analchem.1c03665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
![]()
Fibrinogen
concentration is a major determinant of both clotting
and bleeding risk. Clotting and bleeding disorders cause extensive
morbidity and mortality, particularly in resource-poor and emergency
settings. This is exacerbated by a lack of timely intervention informed
by measurement of fibrinogen levels under conditions such as thrombosis
or postpartum haemorrhage. There is an absence of simple, rapid, low-cost,
and sustainable diagnostic devices for fibrinogen measurement that
can be deployed in such environments. Paper-based analytical devices
are of significant interest due to their potential for low-cost production,
ease of use, and environmental sustainability. In this work, a device
for measuring blood plasma fibrinogen using chromatography paper was
developed. Wax printing was used to create hydrophobic structures
to define the test channel and sample application zone. Test strips
were modified with bovine thrombin. Plasma samples (22 μL) were
applied, and the flow rate was monitored over 5 min. As the sample
traversed the strip, clotting was induced by the conversion of soluble
fibrinogen to insoluble fibrin. The flow rate and distance travelled
by the sample were dependent on fibrinogen concentration. The device
was able to measure fibrinogen concentration in the range of 0.5–7.0
± 0.3 mg/mL (p < 0.05, n = 24) and had excellent correlation with laboratory coagulometry
in artificial samples (r2 = 0.9582, n = 60). Devices were also stable at 4–6 °C
for up to 3 weeks.
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Affiliation(s)
- Jerro Saidykhan
- Centre for Research in Biosciences (CRIB), Department of Applied Sciences, University of the West of England, Coldhar-bour Lane, Bristol BS16 1QY, U.K
| | - Laura Selevic
- Centre for Research in Biosciences (CRIB), Department of Applied Sciences, University of the West of England, Coldhar-bour Lane, Bristol BS16 1QY, U.K
| | - Stefano Cinti
- Department of Pharmacy, University of Naples "Federico II", Via Domenico Montesano 49, Napoli 80131, Italy
| | - Jennifer E May
- Centre for Research in Biosciences (CRIB), Department of Applied Sciences, University of the West of England, Coldhar-bour Lane, Bristol BS16 1QY, U.K
| | - Anthony J Killard
- Centre for Research in Biosciences (CRIB), Department of Applied Sciences, University of the West of England, Coldhar-bour Lane, Bristol BS16 1QY, U.K
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53
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Fecher A, Stimpson A, Ferrigno L, Pohlman TH. The Pathophysiology and Management of Hemorrhagic Shock in the Polytrauma Patient. J Clin Med 2021; 10:jcm10204793. [PMID: 34682916 PMCID: PMC8541346 DOI: 10.3390/jcm10204793] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
The recognition and management of life-threatening hemorrhage in the polytrauma patient poses several challenges to prehospital rescue personnel and hospital providers. First, identification of acute blood loss and the magnitude of lost volume after torso injury may not be readily apparent in the field. Because of the expression of highly effective physiological mechanisms that compensate for a sudden decrease in circulatory volume, a polytrauma patient with a significant blood loss may appear normal during examination by first responders. Consequently, for every polytrauma victim with a significant mechanism of injury we assume substantial blood loss has occurred and life-threatening hemorrhage is progressing until we can prove the contrary. Second, a decision to begin damage control resuscitation (DCR), a costly, highly complex, and potentially dangerous intervention must often be reached with little time and without sufficient clinical information about the intended recipient. Whether to begin DCR in the prehospital phase remains controversial. Furthermore, DCR executed imperfectly has the potential to worsen serious derangements including acidosis, coagulopathy, and profound homeostatic imbalances that DCR is designed to correct. Additionally, transfusion of large amounts of homologous blood during DCR potentially disrupts immune and inflammatory systems, which may induce severe systemic autoinflammatory disease in the aftermath of DCR. Third, controversy remains over the composition of components that are transfused during DCR. For practical reasons, unmatched liquid plasma or freeze-dried plasma is transfused now more commonly than ABO-matched fresh frozen plasma. Low-titer type O whole blood may prove safer than red cell components, although maintaining an inventory of whole blood for possible massive transfusion during DCR creates significant challenges for blood banks. Lastly, as the primary principle of management of life-threatening hemorrhage is surgical or angiographic control of bleeding, DCR must not eclipse these definitive interventions.
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Affiliation(s)
- Alison Fecher
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Anthony Stimpson
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Lisa Ferrigno
- Department of Surgery, UCHealth, University of Colorado-Denver, Aurora, CO 80045, USA;
| | - Timothy H. Pohlman
- Surgery Section, Woodlawn Hospital, Rochester, IN 46975, USA
- Correspondence:
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54
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Liew-Spilger AE, Sorg NR, Brenner TJ, Langford JH, Berquist M, Mark NM, Moore SH, Mark J, Baumgartner S, Abernathy MP. Viscoelastic Hemostatic Assays for Postpartum Hemorrhage. J Clin Med 2021; 10:3946. [PMID: 34501395 PMCID: PMC8432102 DOI: 10.3390/jcm10173946] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 12/15/2022] Open
Abstract
This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.
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Affiliation(s)
- Alyson E. Liew-Spilger
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA;
| | - Nikki R. Sorg
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Toby J. Brenner
- Division of Natural Sciences, Indiana Wesleyan University, Marion, IN 46953, USA;
| | - Jack H. Langford
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN 46208, USA;
| | - Margaret Berquist
- College of Science, University of Notre Dame, Notre Dame, IN 46556, USA;
| | - Natalie M. Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Spencer H. Moore
- Marian University College of Osteopathic Medicine, Indianapolis, IN 46222, USA;
| | - Julie Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Sara Baumgartner
- Department of Obstetrics and Gynecology, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Mary P. Abernathy
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
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55
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Walsh M, Kwaan H, McCauley R, Marsee M, Speybroeck J, Thomas S, Hatch J, Vande Lune S, Grisoli A, Wadsworth S, Shariff F, Aversa JG, Shariff F, Zackariya N, Khan R, Agostini V, Campello E, Simioni P, Scărlătescu E, Hartmann J. Viscoelastic testing in oncology patients (including for the diagnosis of fibrinolysis): Review of existing evidence, technology comparison, and clinical utility. Transfusion 2021; 60 Suppl 6:S86-S100. [PMID: 33089937 DOI: 10.1111/trf.16102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 12/23/2022]
Abstract
The quantification of the coagulopathic state associated with oncologic and hematologic diseases is imperfectly assessed by common coagulation tests such as prothrombin time, activated partial thromboplastin time, fibrinogen levels, and platelet count. These tests provide a static representation of a component of hemostatic integrity, presenting an incomplete picture of coagulation in these patients. Viscoelastic tests (VETs), such as rotational thromboelastometry (ROTEM) and thromboelastography (TEG), as whole blood analyses, provide data related to the cumulative effects of blood components and all stages of the coagulation and fibrinolytic processes. The utility of VETs has been demonstrated since the late 1960s in guiding blood component therapy for patients undergoing liver transplantation. Since then, the scope of viscoelastic testing has expanded to become routinely used for cardiac surgery, obstetrics, and trauma. In the past decade, VETs' expanded usage has been most significant in trauma resuscitation. However, use of VETs for patients with malignancy-associated coagulopathy (MAC) and hematologic malignancies is increasing. For the purposes of this narrative review, we discuss the similarities between trauma-induced coagulopathy (TIC) and MAC. These similarities center on the thrombomodulin-thrombin complex as it switches between the thrombin-activatable fibrinolysis inhibitor coagulation pathway and activating the protein C anticoagulation pathway. This produces a spectrum of coagulopathy and fibrinolytic alterations ranging from shutdown to hyperfibrinolysis that are common to TIC, MAC, and hematologic malignancies. There is expanding literature regarding the utility of TEG and ROTEM to describe the hemostatic integrity of patients with oncologic and hematologic conditions, which we review here.
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Affiliation(s)
- Mark Walsh
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA.,Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana, USA.,Indiana University School of Medicine, South Bend, Indiana, USA
| | - Hau Kwaan
- Department of Hematology Oncology, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Ross McCauley
- Indiana University School of Medicine, South Bend, Indiana, USA
| | - Mathew Marsee
- Indiana University School of Medicine, South Bend, Indiana, USA
| | | | - Scott Thomas
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana, USA
| | - Jordan Hatch
- Indiana University School of Medicine, South Bend, Indiana, USA
| | | | - Anne Grisoli
- Indiana University School of Medicine, South Bend, Indiana, USA
| | - Sarah Wadsworth
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana, USA
| | - Faisal Shariff
- Indiana University School of Medicine, South Bend, Indiana, USA
| | - John G Aversa
- Department of General Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Faadil Shariff
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA
| | - Nuha Zackariya
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana, USA
| | - Rashid Khan
- Michiana Hematology Oncology, Mishawaka, Indiana, USA
| | - Vanessa Agostini
- Department of Transfusion Medicine, IRCC Polyclinic Hospital San Marino, Genoa, Italy
| | - Elena Campello
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Escaterina Scărlătescu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Jan Hartmann
- Department of Medical Affairs, Haemonetics Corporation, Boston, Massachusetts, USA
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56
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Speybroeck J, Marsee M, Shariff F, Zackariya N, Grisoli A, Lune SV, Larson EE, Hatch J, McCauley R, Shariff F, Aversa JG, Son M, Agostini V, Campello E, Simioni P, Scărlătescu E, Kwaan H, Hartmann J, Fries D, Walsh M. Viscoelastic testing in benign hematologic disorders: Clinical perspectives and future implications of point-of-care testing to assess hemostatic competence. Transfusion 2021; 60 Suppl 6:S101-S121. [PMID: 33089936 DOI: 10.1111/trf.16088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/04/2020] [Accepted: 09/05/2020] [Indexed: 01/04/2023]
Abstract
Viscoelastic tests (VETs) have been used routinely for liver transplantation, cardiac surgery, and trauma, but only recently have found clinical utility in benign hematologic disorders. Therefore, guidelines for diagnosis and treatment of these disorders based on viscoelastic variables have been adapted from the existing transplant, cardiothoracic surgery, and trauma resuscitation literature. As a result, diagnostic and therapeutic strategies for benign hematologic disorders utilizing VETs are not uniform. Accordingly, even though there has been a recent increase in the utilization of VET for the diagnosis and treatment of such disorders, the literature is still in its early stages. Analysis of point-of-care viscoelastic tracings from benign hematologic disorders has the potential to allow prompt recognition of disease and to guide patient-specific intervention. Here we present a review describing the application of VETs to benign hematologic disorders.
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Affiliation(s)
- Jacob Speybroeck
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Mathew Marsee
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Faadil Shariff
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Nuha Zackariya
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Anne Grisoli
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Stefani Vande Lune
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Emilee E Larson
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Jordan Hatch
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Ross McCauley
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Faisal Shariff
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of General Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael Son
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Vanessa Agostini
- Department of Transfusion Medicine, IRCC Polyclinic Hospital San Marino, Genoa, Italy
| | - Elena Campello
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Escaterina Scărlătescu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Hau Kwaan
- Department of Hematology Oncology, Northwestern University School of Medicine, Chicago, Illinois
| | - Jan Hartmann
- Department of Medical Affairs, Haemonetics Corporation, Boston, Massachusetts
| | - Dietmar Fries
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Mark Walsh
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana.,Saint Joseph Regional Medical Center, Mishawaka, Indiana
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57
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Racine-Brzostek SE, Asmis LM. Assessment of platelet function utilizing viscoelastic testing. Transfusion 2021; 60 Suppl 6:S10-S20. [PMID: 33089932 DOI: 10.1111/trf.16081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/29/2020] [Accepted: 08/29/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Sabrina E Racine-Brzostek
- Department of Pathology and Laboratory Medicine, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
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58
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Bunch CM, Thomas AV, Stillson JE, Gillespie L, Khan RZ, Zackariya N, Shariff F, Al-Fadhl M, Mjaess N, Miller PD, McCurdy MT, Fulkerson DH, Miller JB, Kwaan HC, Moore EE, Moore HB, Neal MD, Martin PL, Kricheff ML, Walsh MM. Preventing Thrombohemorrhagic Complications of Heparinized COVID-19 Patients Using Adjunctive Thromboelastography: A Retrospective Study. J Clin Med 2021; 10:jcm10143097. [PMID: 34300263 PMCID: PMC8303660 DOI: 10.3390/jcm10143097] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/05/2021] [Accepted: 07/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The treatment of COVID-19 patients with heparin is not always effective in preventing thrombotic complications, but can also be associated with bleeding complications, suggesting a balanced approach to anticoagulation is needed. A prior pilot study supported that thromboelastography and conventional coagulation tests could predict hemorrhage in COVID-19 in patients treated with unfractionated heparin or enoxaparin, but did not evaluate the risk of thrombosis. METHODS This single-center, retrospective study included 79 severely ill COVID-19 patients anticoagulated with intermediate or therapeutic dose unfractionated heparin. Two stepwise logistic regression models were performed with bleeding or thrombosis as the dependent variable, and thromboelastography parameters and conventional coagulation tests as the independent variables. RESULTS Among all 79 patients, 12 (15.2%) had bleeding events, and 20 (25.3%) had thrombosis. Multivariate logistic regression analysis identified a prediction model for bleeding (adjusted R2 = 0.787, p < 0.001) comprised of increased reaction time (p = 0.016), decreased fibrinogen (p = 0.006), decreased D-dimer (p = 0.063), and increased activated partial thromboplastin time (p = 0.084). Multivariate analysis of thrombosis identified a weak prediction model (adjusted R2 = 0.348, p < 0.001) comprised of increased D-dimer (p < 0.001), decreased reaction time (p = 0.002), increased maximum amplitude (p < 0.001), and decreased alpha angle (p = 0.014). Adjunctive thromboelastography decreased the use of packed red cells (p = 0.031) and fresh frozen plasma (p < 0.001). CONCLUSIONS Significantly, this study demonstrates the need for a precision-based titration strategy of anticoagulation for hospitalized COVID-19 patients. Since severely ill COVID-19 patients may switch between thrombotic or hemorrhagic phenotypes or express both simultaneously, institutions may reduce these complications by developing their own titration strategy using daily conventional coagulation tests with adjunctive thromboelastography.
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Affiliation(s)
- Connor M. Bunch
- Department of Internal Medicine, Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (C.M.B.); (A.V.T.); (J.E.S.); (N.Z.)
| | - Anthony V. Thomas
- Department of Internal Medicine, Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (C.M.B.); (A.V.T.); (J.E.S.); (N.Z.)
| | - John E. Stillson
- Department of Internal Medicine, Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (C.M.B.); (A.V.T.); (J.E.S.); (N.Z.)
| | - Laura Gillespie
- Department of Quality Assurance and Performance Improvement, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Rashid Z. Khan
- Department of Hematology, Michiana Hematology Oncology, Mishawaka, IN 46545, USA;
| | - Nuha Zackariya
- Department of Internal Medicine, Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (C.M.B.); (A.V.T.); (J.E.S.); (N.Z.)
| | - Faadil Shariff
- Department of Internal Medicine, Boston University School of Medicine, Boston, MA 02118, USA;
| | - Mahmoud Al-Fadhl
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (M.A.-F.); (N.M.)
| | - Nicolas Mjaess
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (M.A.-F.); (N.M.)
| | - Peter D. Miller
- Department of Interventional Radiology, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Michael T. McCurdy
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Daniel H. Fulkerson
- Department of Neurosurgery, Beacon Medical Group, South Bend, IN 46601, USA;
| | - Joseph B. Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48202, USA;
| | - Hau C. Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Ernest E. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO 80204, USA; (E.E.M.); (H.B.M.)
| | - Hunter B. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO 80204, USA; (E.E.M.); (H.B.M.)
| | - Matthew D. Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Peter L. Martin
- Department of Emergency Medicine, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA;
| | - Mark L. Kricheff
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Mark M. Walsh
- Department of Internal Medicine, Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (C.M.B.); (A.V.T.); (J.E.S.); (N.Z.)
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (M.A.-F.); (N.M.)
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
- Correspondence:
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Roberts TCD, De Lloyd L, Bell SF, Cohen L, James D, Ridgway A, Jenkins V, Field V, Collis RE, Collins PW. Utility of viscoelastography with TEG 6s to direct management of haemostasis during obstetric haemorrhage: a prospective observational study. Int J Obstet Anesth 2021; 47:103192. [PMID: 34144351 DOI: 10.1016/j.ijoa.2021.103192] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 04/29/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The TEG 6s is an automated cartridge-based device with limited description of use in obstetric haemorrhage. The aim of this analysis was to describe the utility of TEG 6s in identifying abnormal laboratory results of coagulation and platelet count, and inform an interventional treatment algorithm for postpartum haemorrhage. METHODS A prospective observational cohort study of 521 women with moderate to severe obstetric haemorrhage (>1000 mL blood loss), including 372 women with at least one TEG 6s test. A non-pregnant control group was used for reference. TEG 6s test parameters Citrated Functional Fibrinogen (CFF), Citrated Kaolin TEG (CK) and Citrated Rapid TEG (CRT) were compared with paired laboratory tests of fibrinogen, PT/aPTT and platelet count, obtained during haemorrhage. RESULTS Among 456 TEG 6s tests, 389 were matched with laboratory coagulation results. The receiver operator characteristic area-under-the-curve (95% CI) for CFF amplitude by 10 min to detect Clauss fibrinogen ≤2 g/L was 0.95 (0.91 to 0.99) (P<0.0001, sensitivity 0.74 and specificity 0.97 at ≤17 mm). False positives had median (IQR) Clauss fibrinogen of 2.4 (2.3-2.7) g/L. The CK-R time had some utility for detecting prolonged PT/aPTT, however a threshold for fresh frozen plasma transfusion was not established. A CRT maximum amplitude <57 mm, when CFF was ≥15 mm, identified four of eight samples with platelet count <75 × 109/L. CONCLUSION The TEG 6s CFF can be used to identify low fibrinogen during obstetric haemorrhage. A value to identify transfusion thresholds for PT/aPTT and platelets was not established, and laboratory results should continue to be used.
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Affiliation(s)
- T C D Roberts
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
| | - L De Lloyd
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
| | - S F Bell
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
| | - L Cohen
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
| | - D James
- Midwifery, Cardiff & Vale University Health Board, UK
| | - A Ridgway
- Midwifery, Cardiff & Vale University Health Board, UK
| | - V Jenkins
- Haemostasis and Thrombosis, Cardiff & Vale University Health Board, UK
| | - V Field
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
| | - R E Collis
- Department of Anaesthetics, Cardiff & Vale University Health Board, UK
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Bell SF, Collis RE, Pallmann P, Bailey C, James K, John M, Kelly K, Kitchen T, Scarr C, Watkins A, Edey T, Macgillivray E, Greaves K, Volikas I, Tozer J, Sengupta N, Roberts I, Francis C, Collins PW. Reduction in massive postpartum haemorrhage and red blood cell transfusion during a national quality improvement project, Obstetric Bleeding Strategy for Wales, OBS Cymru: an observational study. BMC Pregnancy Childbirth 2021; 21:377. [PMID: 33992094 PMCID: PMC8126150 DOI: 10.1186/s12884-021-03853-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 05/05/2021] [Indexed: 12/22/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality and its incidence is increasing in many countries despite management guidelines. A national quality improvement programme called the Obstetric Bleeding Strategy for Wales (OBS Cymru) was introduced in all obstetric units in Wales. The aim was to reduce moderate PPH (1000 mL) progressing to massive PPH (> 2500 mL) and the need for red cell transfusion. Methods A PPH care bundle was introduced into all 12 obstetric units in Wales included all women giving birth in 2017 and 2018 (n = 61,094). The care bundle prompted: universal risk assessment, quantitative measurement of blood loss after all deliveries (as opposed to visual estimation), structured escalation to senior clinicians and point-of-care viscoelastometric-guided early fibrinogen replacement. Data were submitted by each obstetric unit to a national database. Outcome measures were incidence of massive PPH (> 2500 mL) and red cell transfusion. Analysis was performed using linear regression of the all Wales monthly data. Results Uptake of the intervention was good: quantitative blood loss measurement and risk assessment increased to 98.1 and 64.5% of all PPH > 1000 mL, whilst ROTEM use for PPH > 1500 mL increased to 68.2%. Massive PPH decreased by 1.10 (95% CI 0.28 to 1.92) per 1000 maternities per year (P = 0.011). Fewer women progressed from moderate to massive PPH in the last 6 months, 74/1490 (5.0%), than in the first 6 months, 97/1386 (7.0%), (P = 0.021). Units of red cells transfused decreased by 7.4 (95% CI 1.6 to 13.2) per 1000 maternities per year (P = 0.015). Red cells were transfused to 350/15204 (2.3%) and 268/15150 (1.8%) (P = 0.001) in the first and last 6 months, respectively. There was no increase in the number of women with lowest haemoglobin below 80 g/L during this time period. Infusions of fresh frozen plasma fell and there was no increase in the number of women with haemostatic impairment. Conclusions The OBS Cymru care bundle was feasible to implement and associated with progressive, clinically significant improvements in outcomes for PPH across Wales. It is applicable across obstetric units of widely varying size, complexity and staff mixes. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03853-y.
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Affiliation(s)
- Sarah F Bell
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Rachel E Collis
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Philip Pallmann
- Deputy Director Research Design and Conduct Centre, Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Christopher Bailey
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Kathryn James
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Miriam John
- Department of Emergency Medicine, Aneurin Bevan University Health Board, Newport, UK
| | - Kevin Kelly
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Thomas Kitchen
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Cerys Scarr
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Adam Watkins
- Improvement Cymru, Public Health Wales, Cardiff, UK
| | - Tracey Edey
- Department of Midwifery, Singleton Hospital, Swansea, UK
| | | | - Kathryn Greaves
- Department of Obstetrics and Gynaecology, Cwm Taf Morgannwg Health Board, Merthyr Tydfil, UK
| | - Ingrid Volikas
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - James Tozer
- Department of Anaesthetics and Intensive Care, Aneurin Bevan University Health Board, Newport, UK
| | - Niladri Sengupta
- Department of Obstetrics and Gynaecology, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Iolo Roberts
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Claire Francis
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Peter W Collins
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK.
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Viscoelastic Coagulation Testing: Use and Current Limitations in Perioperative Decision-making. Anesthesiology 2021; 135:342-349. [PMID: 33979438 DOI: 10.1097/aln.0000000000003814] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Gooneratne LV, Dharmasena I, Premawardana N, Wimalachandra M, Arya R, Gnanathasan A. Comparison of rotational thromboelastometry parameters with 20-minute whole blood clotting test as a predictor of envenoming in Russell's viper bite patients. Trans R Soc Trop Med Hyg 2021; 115:561-565. [PMID: 33822235 DOI: 10.1093/trstmh/trab052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/22/2021] [Accepted: 03/05/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Coagulopathy is an important and common systemic clinical syndrome caused by snake envenoming. The major clinical effect of Russell's viper (RV) envenoming is haematotoxicity. The 20-min whole blood clotting test (WBCT20) is the standard test for identification of envenoming in resource-limited settings. However, its reliability as a diagnostic test has been questioned. Rotational thromboelastometry (ROTEM) assays different phases of clot formation from initiation to fibrinolysis. Our objective was to compare parameters of ROTEM with WBCT20 and the international normalized ratio (INR) as predictors of envenoming in RV bite patients. METHODS Fifty-three patents with RV bite presenting to Anuradhapura Hospital, Sri Lanka were recruited. Epidemiological and clinical data were obtained. Venous blood samples were collected at admission for ROTEM, INR and WBCT20. RESULTS A total of 46 of 53 patients with RV bites received antivenom serum (AVS); 74% had a non-clottable WBCT20. All 46 had at least one abnormal ROTEM parameter and 93% had a prolonged EXTEM clotting time (EXTEM-CT). The sensitivity of a prolonged INR was only 55%. CONCLUSIONS EXTEM-CT is a better predictor of envenoming and the need for AVS than WBCT20 in RV bites (p=0.02). It provides a numerical value that can be used post-AVS to objectively assess the response and decide on further treatment.
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Affiliation(s)
| | - Iresha Dharmasena
- Department of Haematology, Teaching Hospital Anuradhapura, Anuradhapura, Sri Lanka
| | - Nuwan Premawardana
- Department of Clinical Medicine University of Rajarata, Anuradhapura, Sri Lanka
| | | | - Roopen Arya
- Department of Haematological Medicine, King's College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Ariaranee Gnanathasan
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
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Advances in anesthetic and obstetric management of patients with placenta accreta spectrum. Curr Opin Anaesthesiol 2021; 34:260-268. [PMID: 33935172 DOI: 10.1097/aco.0000000000000985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The incidence of placenta accreta spectrum is increasing and it is a leading cause of peripartum hysterectomy and massive postpartum hemorrhage. The purpose of the present article is to provide a contemporary overview of placenta accreta spectrum pertinent to the obstetric anesthesiologist. RECENT FINDINGS Recent changes in the terminology used to report invasive placentation were proposed to clarify diagnostic criteria and guidelines for use in clinical practice. Reduced morbidity is associated with scheduled preterm delivery in a center of excellence using a multidisciplinary team approach. Neuraxial anesthesia as a primary technique is increasingly being used despite the known risk of major bleeding. The use of viscoelastic testing and endovascular interventions may aid hemostatic resuscitation and improve outcomes. SUMMARY Accurate diagnosis and early antenatal planning among team members are essential. Obstetric anesthesiologists should be prepared to manage a massive hemorrhage, transfusion, and associated coagulopathy. Increasingly, viscoelastic tests are being used to assess coagulation status and the ability to interpret these results is required to guide the transfusion regimen. Balloon occlusion of the abdominal aorta has been proposed as an intervention that could improve outcomes in women with placenta accreta spectrum, but high-quality safety and efficacy data are lacking.
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Li S, Hu D, Li P, Xiao W, Li H, Liu G, Song Y, Ning S, Peng Q, Zhao D, Situ M, Li W, Wu P, Zheng J, Liu Y, Hu L, Wang P, Hu Z, Ma W, Shen J, Yang S. Parameters Indicating Development of Influenza-Associated Acute Necrotizing Encephalopathy: Experiences from a Single Center. Med Sci Monit 2021; 27:e930688. [PMID: 33934098 PMCID: PMC8101270 DOI: 10.12659/msm.930688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Influenza-associated acute necrotizing encephalopathy (IANE) can be lethal and disabling and have a sudden onset and deteriorate rapidly but lacks early diagnostic indicators. We aimed to examine the early clinical diagnostic indicators in children with IANE. Material/Methods Acute influenza patients were grouped according to their clinical manifestations: flu alone (FA), flu with febrile seizure (FS), influenza-associated encephalopathy (IAE), and IANE. The clinical features, biomarkers, neuroelectrophysiological results, and neuroimaging examination results were compared. Results A total of 31 patients were included (FA (n=4), FS (n=8), IAE (n=14), and IANE (n=5)). The IANE group, whose mean age was 3.7 years, was more likely to show rapid-onset seizure, acute disturbance of consciousness (ADOC), Babinski’s sign, and death/sequela. More patients in the IANE group required tracheal intubation mechanical ventilation and received intravenous immunoglobulins (IVIG) and glucocorticoids. The alanine aminotransferase (ALT), aspartate transaminase (AST), and lactate dehydrogenase (LDH) levels in the IANE group were significantly higher than in the FS and IAE groups. The aquaporin-4 (AQP-4) antibody and malondialdehyde (MDA) levels in the serum and cerebrospinal fluid (CSF) were notably higher in IANE patients in the acute stage compared with FS and IAE patients. All patients in the IANE group had positive neuroimaging findings. Conclusions Early clinical warning factors for IANE include rapid-onset seizures in patients under 4 years of age, ADOC, and pathological signs. Increased AQP-4 antibodies and MDA levels in CSF might contribute to early diagnosis. Early magnetic resonance venography (MRV) and susceptibility-weighted imaging (SWI) sequences, or thrombelastography to identify deep vein thrombosis, might indicate clinical deterioration.
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Affiliation(s)
- Suyun Li
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Dandan Hu
- Department of Pediatric Neurology, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Peiqing Li
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Weiqiang Xiao
- Department of Radiology, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Huixian Li
- Data Statistics Center, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Guangming Liu
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Yongling Song
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Shuyao Ning
- Department of Pediatric Neurology, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Qiuyan Peng
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Danyang Zhao
- Department of Disease Control and Prevention, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Minxiong Situ
- Department of Disease Control and Prevention, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Wanqi Li
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Peiqun Wu
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Jipeng Zheng
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Yueting Liu
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Lin Hu
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Pengfei Wang
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Zhengbin Hu
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Wencheng Ma
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Jun Shen
- Department of Pediatric Emergency Medicine, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
| | - Sida Yang
- Department of Pediatric Neurology, Guangzhou Women's and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China (mainland)
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Grant JK, Ebner B, Vincent L, Maning J, Olorunfemi O, Olarte NI, Colombo R, Munagala M, Chaparro S. Assessing in-hospital cardiovascular, thrombotic and bleeding outcomes in patients with chronic liver disease undergoing left ventricular assist device implantation. Thromb Res 2021; 202:184-190. [PMID: 33892219 DOI: 10.1016/j.thromres.2021.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Chronic liver disease (CLD) and advanced heart failure (HF) often co-exist with coagulopathy and hematologic abnormalities being major concerns in this cohort. Perioperative outcomes of patients undergoing LVAD implantation can be affected by coagulopathy, associated with a higher International Normalized Ratio (INR) and cytopenias, as well as pre-operative use of antiplatelet therapy and systemic anticoagulation. Our study is aimed at evaluating the in-hospital mortality and clinical outcomes of patients with CLD who underwent LVAD implantation compared to patients who underwent LVAD implantation without CLD. METHODS The National Inpatient Sample Database was queried from 2012 to 2017 for relevant International Classification of Diseases (ICD)-9 and ICD-10 procedural and diagnostic codes. Baseline characteristics and in-hospital outcomes were compared in patients with chronic liver disease and those without, who underwent LVAD implantation. RESULTS A total of 22,955 patients underwent LVAD implantation, 2200 of which had CLD. There was no difference in mean age between those with and without CLD (52.8 ± 14.2 vs. 55.7 ± 15.4 years old, p < 0.001), and 23.7% of patients were female. The proportion of patients with CLD undergoing LVAD implantation trended downward between 2012 and 2017 (average annual growth rate: "-14.8%"). In-hospital post-LVAD outcomes revealed: all-cause inpatient mortality (14.8% vs. 11.1%), major bleeding (34.3% vs. 30.2%), transfusion of platelets (18.0% vs. 14.0%), subarachnoid hemorrhage (1.6% vs. 0.7%) and hospital length of stay were greater in patients with CLD (p < 0.001 for all values). LVAD thrombosis (6.6% vs. 9.4%) and postoperative ischemic stroke (3.4% vs. 6.1%) occurred less in patients with CLD (p < 0.001 for both). There were no statistically significant differences in occurrence of post-LVAD gastrointestinal bleeding and transfusion of fresh frozen plasma or packed red blood cells (p > 0.05 for all). Using a multivariate logistic regression model to adjust for confounding factors, CLD was predictive of increased in-hospital all-cause mortality in patients undergoing LVAD implantation (adjusted odds ratio: 1.29, 95% confidence interval [CI]; 1.06 to 1.56, p = 0.010). CONCLUSION LVAD implantation in patients with chronic liver disease was associated with increased mortality and post-LVAD major bleeding with increased utilization of platelet products yet comparable thrombotic complications. Further studies are needed to evaluate the balance and pathophysiology of bleeding risks when compared to thrombosis, as well as predictors in patients with chronic liver disease.
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Affiliation(s)
- Jelani K Grant
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, United States of America.
| | - Bertrand Ebner
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, United States of America
| | - Louis Vincent
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, United States of America
| | - Jennifer Maning
- Department of Internal Medicine, University of Miami/Jackson Memorial Hospital, United States of America
| | - Odunayo Olorunfemi
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, United States of America
| | - Neal I Olarte
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, United States of America
| | - Rosario Colombo
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, United States of America
| | - Mrudula Munagala
- Cardiovascular Division, University of Miami Miller School of Medicine/Jackson Memorial Hospital, United States of America
| | - Sandra Chaparro
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, United States of America
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Bareille M, Hardy M, Douxfils J, Roullet S, Lasne D, Levy JH, Stépanian A, Susen S, Frère C, Lecompte T, Mullier F. Viscoelastometric Testing to Assess Hemostasis of COVID-19: A Systematic Review. J Clin Med 2021; 10:jcm10081740. [PMID: 33923851 PMCID: PMC8072929 DOI: 10.3390/jcm10081740] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 02/06/2023] Open
Abstract
Infection by SARS-CoV-2 is associated with a high risk of thrombosis. The laboratory documentation of hypercoagulability and impaired fibrinolysis remains a challenge. Our aim was to assess the potential usefulness of viscoelastometric testing (VET) to predict thrombotic events in COVID-19 patients according to the literature. We also (i) analyzed the impact of anticoagulation and the methods used to neutralize heparin, (ii) analyzed whether maximal clot mechanical strength brings more information than Clauss fibrinogen, and (iii) critically scrutinized the diagnosis of hypofibrinolysis. We performed a systematic search in PubMed and Scopus databases until 31st December 2020. VET methods and parameters, and patients' features and outcomes were extracted. VET was performed for 1063 patients (893 intensive care unit (ICU) and 170 non-ICU, 44 studies). There was extensive heterogeneity concerning study design, VET device used (ROTEM, TEG, Quantra and ClotPro) and reagents (with non-systematic use of heparin neutralization), timing of assay, and definition of hypercoagulable state. Notably, only 4 out of 25 studies using ROTEM reported data with heparinase (HEPTEM). The common findings were increased clot mechanical strength mainly due to excessive fibrinogen component and impaired to absent fibrinolysis, more conspicuous in the presence of an added plasminogen activator. Only 4 studies out of the 16 that addressed the point found an association of VETs with thrombotic events. So-called functional fibrinogen assessed by VETs showed a variable correlation with Clauss fibrinogen. Abnormal VET pattern, often evidenced despite standard prophylactic anticoagulation, tended to normalize after increased dosing. VET studies reported heterogeneity, and small sample sizes do not support an association between the poorly defined prothrombotic phenotype of COVID-19 and thrombotic events.
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Affiliation(s)
- Marion Bareille
- Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
- Correspondence:
| | - Michaël Hardy
- Service D’anesthésiologie, CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC), Département de Pharmacie, Université de Namur, 5000 Namur, Belgium;
- Qualiblood S.A., 5000 Namur, Belgium
| | - Stéphanie Roullet
- CHU Bordeaux, Service D’Anesthésie-Réanimation Tripode, 33000 Bordeaux, France;
- Biologie des Maladies Cardiovasculaire, University Bordeaux, INSERM U1034, 33600 Pessac, France
| | - Dominique Lasne
- Laboratoire D’hématologie Générale, Hôpital Universitaire Necker-Enfants Malades, AP-HP, 75015 Paris, France;
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC 27710, USA;
| | - Alain Stépanian
- Hôpital Lariboisière, Service D’Hématologie Biologique, Institut de Recherche Saint-Louis, Université de Paris, AP-HP Nord-Université de Paris, EA 3518, 75010 Paris, France;
| | - Sophie Susen
- Laboratoire D’Hématologie-Hémostase, Université de Lille, CHU Lille, 59037 Lille, France;
| | - Corinne Frère
- Department of Hematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, INSERM UMRS_1166, Sorbonne Université, 75013 Paris, France;
| | - Thomas Lecompte
- Départements de Médecine, Service D’angiologie et D’hémostase et Faculté de Médecine Geneva Platelet Group (GpG), Université de Genève et Hôpitaux Universitaires de Genève, 1205 Genève, Switzerland;
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
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Collis RE, Kenyon C, Roberts TCD, McNamara H. When does obstetric coagulopathy occur and how do I manage it? Int J Obstet Anesth 2021; 46:102979. [PMID: 33906823 DOI: 10.1016/j.ijoa.2021.102979] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/20/2021] [Accepted: 03/08/2021] [Indexed: 01/22/2023]
Abstract
Anticipating obstetric coagulopathy is important when obstetric anaesthetists are involved in the clinical management of women with postpartum haemorrhage. Although the incidence of coagulopathy in women with postpartum haemorrhage is low, significant hypofibrinogenaemia is associated with major haemorrhage-related morbidity and thus early identification and treatment is essential to improve outcomes. Point-of-care viscoelastic haemostatic assays, including thromboelastography and rotational thromboelastometry, provide granular information about alterations in clot formation and hypofibrinogenaemia, allow near-patient interpretation of coagulopathy, and can guide goal-directed treatment. If these assays are not available, anaesthetists should closely monitor the maternal coagulation profile with standard laboratory testing during the active phase of postpartum bleeding in order to rule coagulopathy 'in or out', decide if pro-haemostatic therapies are indicated, and assess the response to haemostatic support.
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Affiliation(s)
- R E Collis
- University Hospital of Wales, Cardiff, UK.
| | - C Kenyon
- Liverpool Women's Hospital NHS Trust, Liverpool, UK
| | | | - H McNamara
- Liverpool Women's Hospital NHS Trust, Liverpool, UK
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Mok G, Hoang R, Khan MW, Pannell D, Peng H, Tien H, Nathens A, Callum J, Karkouti K, Beckett A, da Luz LT. Freeze-dried plasma for major trauma - Systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 90:589-602. [PMID: 33507025 PMCID: PMC7899224 DOI: 10.1097/ta.0000000000003012] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Treatment of acute trauma coagulopathy has shifted toward rapid replacement of coagulation factors with frozen plasma (FP). There are logistic difficulties in providing FP. Freeze-dried plasma (FDP) may have logistical advantages including easier storage and rapid preparation time. This review assesses the feasibility, efficacy, and safety of FDP in trauma. STUDY DESIGN AND METHODS Studies were searched from Medline, Embase, Cochrane Controlled Trials Register, ClinicalTrials.gov, and Google Scholar. Observational and randomized controlled trials (RCTs) assessing FDP use in trauma were included. Trauma animal models addressing FDP use were also included. Bias was assessed using validated tools. Primary outcome was efficacy, and secondary outcomes were feasibility and safety. Meta-analyses were conducted using random-effect models. Evidence was graded using Grading of Recommendations Assessment, Development, and Evaluation profile. RESULTS Twelve human studies (RCT, 1; observational, 11) and 15 animal studies were included. Overall, studies demonstrated moderate risk of bias. Data from two studies (n = 119) were combined for meta-analyses for mortality and transfusion of allogeneic blood products (ABPs). For both outcomes, no difference was identified. For mortality, pooled odds ratio was 0.66 (95% confidence interval, 0.29-1.49), with I2 = 0%. Use of FDP is feasible, and no adverse events were reported. Animal data suggest similar results for coagulation and anti-inflammatory profiles for FP and FDP. CONCLUSION Human data assessing FDP use in trauma report no difference in mortality and transfusion of ABPs in patients receiving FDP compared with FP. Data from animal trauma studies report no difference in coagulation factor and anti-inflammatory profiles between FP and FDP. Results should be interpreted with caution because most studies were observational and have heterogeneous population (military and civilian trauma) and a moderate risk of bias. Well-designed prospective observational studies or, preferentially, RCTs are warranted to answer FDP's effect on laboratory (coagulation factor levels), transfusion (number of ABPs), and clinical outcomes (organ dysfunction, length of stay, and mortality). LEVEL OF EVIDENCE Systematic review and meta-analysis, level IV.
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69
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Modern methods for monitoring hemorrhagic resuscitation in the United States: Why the delay? J Trauma Acute Care Surg 2021; 89:1018-1022. [PMID: 33048910 DOI: 10.1097/ta.0000000000002977] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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70
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Global coagulation assays in healthy controls: are there compensatory mechanisms within the coagulation system? J Thromb Thrombolysis 2021; 52:610-619. [PMID: 33625645 DOI: 10.1007/s11239-021-02400-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
Global coagulation assays (GCAs) may provide a more comprehensive individual hemostatic profiling. We aim to evaluate GCAs (thromboelastography, thrombin generation) in healthy controls, and correlate results with age, gender, lipid status, tissue factor pathway inhibitor (TFPI) and P-selectin. Blood samples were collected from healthy controls (> 18 years of age) not taking anticoagulation or antiplatelet agents and without known cardiovascular disease. Thromboelastography (TEG) was performed on citrated whole blood while calibrated automated thrombogram (CAT), P-selectin (endothelial marker) and TFPI (principle inhibitor of tissue factor-initiated coagulation) were performed on platelet-poor plasma. 153 healthy controls (mean age 42 years, 98 females (64%)) were recruited. Female controls demonstrated more hypercoagulable TEG and CAT parameters while those over 50 years of age demonstrated more hypercoagulable TEG parameters despite comparable thrombin generation. Paradoxically, individuals with "flattened" thrombin curves (lower velocity index (rate of thrombin generation) despite preserved endogenous thrombin potential (amount of thrombin)) were more likely to be male (49% vs 20%, p = 0.003) with increased low-density lipoprotein cholesterol (3.3 vs 2.6 mmol/L, p = 0.003), P-selectin (54.2 vs 47.3 ng/mL, p = 0.038) and TFPI (18.7 vs 8.6 ng/ml, p = 0.001). In addition to reduced velocity index and thrombin peak, controls in the highest TFPI tertile also demonstrated a poorer lipid profile. GCAs can detect subtle changes of the hemostatic profile. Interestingly, reduced thrombin generation was paradoxically associated with increased cardiovascular risk factors, possibly attributable to increased TFPI. This finding may suggest compensation by the coagulation system in response to endothelial activation and represent a biomarker for early cardiovascular disease. A larger prospective study evaluating these assays in the cardiovascular disease population is ongoing.
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71
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Potential Utility of Thromboelastography for Patients with Abnormal Coagulation Markers in Interventional Radiology: Report of 3 Cases and Review of Literature. Cardiovasc Intervent Radiol 2021; 44:996-998. [PMID: 33608758 DOI: 10.1007/s00270-021-02780-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
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Lorenzen H, Frøstrup AB, Larsen AS, Fenger MS, Dahdouh S, Zoel-Ghina R, Nielsen LK. Pneumatic tube transport of blood samples affects global hemostasis and platelet function assays. Int J Lab Hematol 2021; 43:1207-1215. [PMID: 33538112 DOI: 10.1111/ijlh.13470] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/26/2020] [Accepted: 12/29/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Pneumatic tube systems (PTS) are frequently used for rapid and cost-effective transportation of blood samples to the clinical laboratory. The impact of PTS transport on platelet function measured by the Multiplate system and global hemostasis measured by the TEG 5000 was evaluated. METHODS Paired samples from healthy adult individuals were obtained at two study sites: Rigshospitalet (RH) and Nordsjaellands Hospital (NOH). One sample was transported by PTS and one manually (non-PTS). Platelet function was assessed by platelet aggregation (Multiplate) and global hemostasis was assessed by a variety of thrombelastography (TEG) assays. Multiplate (n = 39) and TEG (n = 32) analysis was performed at site RH, and Multiplate (n = 28) analysis was performed at site NOH. RESULTS A significant higher agonist-induced platelet aggregation was found for PTS samples compared to manual transport at site NOH (P < .02, all agonists). No significant difference was found at site RH (P > .05, all agonists). For Kaolin TEG, samples transported by PTS showed a significant lower R-time and higher Angle (P < .001). No significant differences in MA and LY30 was found (P > .05). ACT of RapidTEG was significantly reduced (P = .001) and MA of Functional Fibrinogen TEG was significantly increased (P < .001) after PTS transport. No significant impact of PTS was observed for TEG assays with heparinase (P > .05). CONCLUSIONS Depending on the type of PTS, transportation by PTS affected platelet aggregation measured by Multiplate. Furthermore, PTS alters TEG parameters possibly reflecting coagulation factors. Clinical laboratories should evaluate the effect of the local PTS on Multiplate and TEG results.
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Affiliation(s)
| | - Ann-Britt Frøstrup
- Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Immunology, Zealand University Hospital, Roskilde, Denmark
| | - Anja S Larsen
- Department of Clinical Immunology, Nordsjaellands Hospital, Hillerød, Denmark
| | - Michelle S Fenger
- Faculty of Health, University College Copenhagen, Copenhagen, Denmark.,Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark
| | - Sanne Dahdouh
- Faculty of Health, University College Copenhagen, Copenhagen, Denmark.,Department of Clinical Immunology, Nordsjaellands Hospital, Hillerød, Denmark
| | - Randa Zoel-Ghina
- Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark
| | - Leif K Nielsen
- Faculty of Health, University College Copenhagen, Copenhagen, Denmark
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73
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Walsh M, Moore EE, Moore HB, Thomas S, Kwaan HC, Speybroeck J, Marsee M, Bunch CM, Stillson J, Thomas AV, Grisoli A, Aversa J, Fulkerson D, Vande Lune S, Sjeklocha L, Tran QK. Whole Blood, Fixed Ratio, or Goal-Directed Blood Component Therapy for the Initial Resuscitation of Severely Hemorrhaging Trauma Patients: A Narrative Review. J Clin Med 2021; 10:320. [PMID: 33477257 PMCID: PMC7830337 DOI: 10.3390/jcm10020320] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 12/21/2022] Open
Abstract
This narrative review explores the pathophysiology, geographic variation, and historical developments underlying the selection of fixed ratio versus whole blood resuscitation for hemorrhaging trauma patients. We also detail a physiologically driven and goal-directed alternative to fixed ratio and whole blood, whereby viscoelastic testing guides the administration of blood components and factor concentrates to the severely bleeding trauma patient. The major studies of each resuscitation method are highlighted, and upcoming comparative trials are detailed.
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Affiliation(s)
- Mark Walsh
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
- Departments of Emergency & Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Ernest E. Moore
- Ernest E. Moore Shock Trauma Center, Denver Health, Denver, CO 80204, USA;
- Department of Surgery, University of Colorado Health Science Center, Denver, CO 80204, USA;
| | - Hunter B. Moore
- Department of Surgery, University of Colorado Health Science Center, Denver, CO 80204, USA;
| | - Scott Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, Beacon Health System, South Bend, IN 46601, USA;
| | - Hau C. Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Jacob Speybroeck
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Mathew Marsee
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Connor M. Bunch
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - John Stillson
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Anthony V. Thomas
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - Annie Grisoli
- Notre Dame Campus, Indiana University School of Medicine, South Bend, IN 46617, USA; (M.W.); (J.S.); (M.M.); (C.M.B.); (J.S.); (A.V.T.); (A.G.)
| | - John Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Daniel Fulkerson
- Department of Neurosurgery, Beacon Medical Group, South Bend, IN 46601, USA;
| | - Stefani Vande Lune
- Emergency Medicine Department, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA;
| | - Lucas Sjeklocha
- The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Quincy K. Tran
- The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
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74
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Variations and obstacles in the use of coagulation factor concentrates for major trauma bleeding across Europe: outcomes from a European expert meeting. Eur J Trauma Emerg Surg 2021; 48:763-774. [PMID: 33399876 PMCID: PMC7782571 DOI: 10.1007/s00068-020-01563-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 11/19/2020] [Indexed: 12/24/2022]
Abstract
Purpose Trauma is a leading cause of mortality, with major bleeding and trauma-induced coagulopathy (TIC) contributing to negative patient outcomes. Treatments for TIC include tranexamic acid (TXA), fresh frozen plasma (FFP), and coagulation factor concentrates (CFCs, e.g. prothrombin complex concentrates [PCCs] and fibrinogen concentrate [FCH]). Guidelines for TIC management vary across Europe and a clear definition of TIC is still lacking. Methods An advisory board involving European trauma experts was held on 02 February 2019, to discuss clinical experience in the management of trauma-related bleeding and recommendations from European guidelines, focusing on CFC use (mainly FCH). This review summarises the discussions, including TIC definitions, gaps in the guidelines that affect their implementation, and barriers to use of CFCs, with suggested solutions. Results A definition of TIC, which incorporates clinical (e.g. severe bleeding) and laboratory parameters (e.g. low fibrinogen) is suggested. TIC should be treated immediately with TXA and FCH/red blood cells; subsequently, if fibrinogen ≤ 1.5 g/L (or equivalent by viscoelastic testing), treatment with FCH, then PCC (if bleeding continues) is suggested. Fibrinogen concentrate, and not FFP, should be administered as first-line therapy for TIC. Several initiatives may improve TIC management, with improved medical education of major importance; generation of new and stronger data, simplified clinical practice guidance, and improved access to viscoelastic testing are also critical factors. Conclusions Management of TIC is challenging. A standard definition of TIC, together with initiatives to facilitate effective CFC administration, may contribute to improved patient care and outcomes.
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75
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Wei H, Child LJ. Clinical utility of viscoelastic testing in chronic liver disease: A systematic review. World J Hepatol 2020; 12:1115-1127. [PMID: 33312434 PMCID: PMC7701961 DOI: 10.4254/wjh.v12.i11.1115] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/01/2020] [Accepted: 09/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Conventional coagulation tests are widely used in chronic liver disease to assess haemostasis and to guide blood product transfusion. This is despite the fact that conventional tests do not reliably separate those with a clinically significant coagulopathy from those who do not. Viscoelastic testing such as thromboelastography (TEG) correlate with bleeding risk and are more accurate in identifying those who will benefit from blood product transfusion. Despite this, viscoelastic tests have not been widely used in patients with chronic liver disease outside the transplant setting.
AIM To assess the utility of Viscoelastic Testing guided transfusion in chronic liver disease patients presenting with bleeding or who require an invasive procedure.
METHODS PubMed and Google Scholar searches were performed using the key words “thromboelastography”, “TEG” or “viscoelastic” and “liver transplantation”, “cirrhosis” or “liver disease” and “transfusion”, “haemostasis”, “blood management” or “haemorrhage”. A full text review was undertaken and data was extracted from randomised control trials that evaluated the outcomes of viscoelastic test guided transfusion in those with liver disease. The study subjects, inclusion and exclusion criteria, methods, outcomes and length of follow up were examined. Data was extracted by two independent individuals using a standardized collection form. The risk of bias was assessed in the included studies.
RESULTS A total of five randomised control trials included in the analysis examined the use of TEG guided blood product transfusion in cirrhosis prior to invasive procedures (n = 118), non-variceal haemorrhage (n = 96), variceal haemorrhage (n = 60) and liver transplantation (n = 28). TEG guided transfusion was effective in all five studies with a statistically significant reduction in overall blood product transfusion compared to standard of care. Four of the five studies reported a significant reduction in transfusion of fresh frozen plasma and platelets. Two studies showed a significant reduction in cryoprecipitate transfusion. No increased risk of bleeding was reported in the three trials where TEG was used perioperatively or prior to an invasive procedure. Two trials in the setting of cirrhotic variceal and non-variceal bleeding showed no difference in control of initial bleeding. In those with variceal bleeding, there was a statistically significant reduction in rate of re-bleeding at 42 d in the TEG arm 10% (vs 26.7% in the standard of care arm P = 0.012). Mortality data reported at various time points for all five trials from 6 wk up to 3 years was not statistically different between each arm. One trial in the setting of non-variceal bleeding demonstrated a significant reduction in adverse transfusion events in the TEG arm 30.6% (vs 74.5% in the control arm P < 0.01). In this study there was no significant difference in total hospital stay although length of stay in intensive care unit was reduced by an average of 2 d in the TEG arm (P = 0.012).
CONCLUSION Viscoelastic testing has been shown to reduce blood product usage in chronic liver disease without compromising safety and may enable guidelines to be developed to ensure patients with liver disease are optimally managed.
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Affiliation(s)
- Henry Wei
- Department of Gastroenterology and Hepatology, Middlemore Hospital, Auckland 1071, New Zealand
| | - Lauren Jane Child
- Department of Haematology, New Zealand Blood Services Epsom, Auckland 1051, New Zealand
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Shah A, Oczkowski S, Aubron C, Vlaar AP, Dionne JC. Transfusion in critical care: Past, present and future. Transfus Med 2020; 30:418-432. [PMID: 33207388 DOI: 10.1111/tme.12738] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/27/2020] [Indexed: 01/28/2023]
Abstract
Anaemia and coagulopathy are common in critically ill patients and are associated with poor outcomes, including increased risk of mortality, myocardial infarction, failure to be liberated from mechanical ventilation and poor physical recovery. Transfusion of blood and blood products remains the corner stone of anaemia and coagulopathy treatment in critical care. However, determining when the benefits of transfusion outweigh the risks of anaemia may be challenging in some critically ill patients. Therefore, the European Society of Intensive Care Medicine prioritised the development of a clinical practice guideline to address anaemia and coagulopathy in non-bleeding critically ill patients. The aims of this article are to: (1) review the evolution of transfusion practice in critical care and the direction for future developments in this important area of transfusion medicine and (2) to provide a brief synopsis of the guideline development process and recommendations in a format designed for busy clinicians and blood bank staff. These clinical practice guidelines provide recommendations to clinicians on how best to manage non-bleeding critically ill patients at the bedside. More research is needed on alternative transfusion targets, use of transfusions in special populations (e.g., acute neurological injury, acute coronary syndromes), use of anaemia prevention strategies and point-of-care interventions to guide transfusion strategies.
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Affiliation(s)
- Akshay Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,Adult Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada.,Guidelines in Intensive Care, Development and Evaluation (GUIDE) Group, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Cecile Aubron
- Department of Intensive Care Medicine, Centre Hospitalier Regional et Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Alexander P Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, Canada.,Guidelines in Intensive Care, Development and Evaluation (GUIDE) Group, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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Baker P, Platton S, Gibson C, Gray E, Jennings I, Murphy P, Laffan M. Guidelines on the laboratory aspects of assays used in haemostasis and thrombosis. Br J Haematol 2020; 191:347-362. [PMID: 32537743 DOI: 10.1111/bjh.16776] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sean Platton
- Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Claire Gibson
- Specialist Haemostasis, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elaine Gray
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Controls, Hertfordshire, UK
| | | | - Paul Murphy
- Department of Haematology, the Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mike Laffan
- Centre for Haematology, Imperial College and Hammersmith Hospital, London, UK
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78
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Gibbs NM, Weightman WM. Diagnostic accuracy of viscoelastic point-of-care identification of hypofibrinogenaemia in cardiac surgical patients: A systematic review. Anaesth Intensive Care 2020; 48:339-353. [DOI: 10.1177/0310057x20948868] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hypofibrinogenaemia during cardiac surgery may increase blood loss and bleeding complications. Viscoelastic point-of-care tests provide more rapid diagnosis than laboratory measurement, allowing earlier treatment. However, their diagnostic test accuracy for hypofibrinogenaemia has never been reviewed systematically. We aimed to systematically review their diagnostic test accuracy for the identification of hypofibrinogenaemia during cardiac surgery. Two reviewers assessed relevant articles from seven electronic databases, extracted data from eligible articles and assessed quality. The primary outcomes were sensitivity, specificity and positive and negative predictive values. A total of 576 articles were screened and 81 full texts were assessed, most of which were clinical agreement or outcome studies. Only 10 diagnostic test accuracy studies were identified and only nine were eligible (ROTEM delta 7; TEG5000 1; TEG6S 1, n = 1820 patients) (ROTEM, TEM International GmbH, Munich, Germany; TEG, Haemonetics, Braintree, MA, USA). None had a low risk of bias. Four ROTEM studies with a fibrinogen threshold less than 1.5–1.6 g/l and FIBTEM threshold A10 less than 7.5–8 mm had point estimates for sensitivity of 0.61–0.88; specificity 0.54–0.94; positive predictive value 0.42–0.70; and negative predictive value 0.74–0.98 (i.e. false positive rate 30%–58%; false negative rate 2%–26%). Two ROTEM studies with higher thresholds for both fibrinogen (<2 g/l) and FIBTEM A10 (<9.5 mm) had similar false positive rates (25%–46%), as did the two TEG studies (15%–48%). This review demonstrates that there have been few diagnostic test accuracy studies of viscoelastic point-of-care identification of hypofibrinogenaemia in cardiac surgical patients. The studies performed so far report false positive rates of up to 58%, but low false negative rates. Further diagnostic test accuracy studies of viscoelastic point-of-care identification of hypofibrinogenaemia are required to guide their better use during cardiac surgery.
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Affiliation(s)
- Neville M Gibbs
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Australia
- The University of Western Australia, Nedlands, Australia
| | - William M Weightman
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Australia
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79
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Tyler PD, Yang LM, Snider SB, Lerner AB, Aird WC, Shapiro NI. New Uses for Thromboelastography and Other Forms of Viscoelastic Monitoring in the Emergency Department: A Narrative Review. Ann Emerg Med 2020; 77:357-366. [PMID: 32988649 DOI: 10.1016/j.annemergmed.2020.07.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
Patients frequently visit the emergency department with conditions that place them at risk of worse outcomes when accompanied by coagulopathy. Routine tests of coagulation-prothrombin time, partial thromboplastin time, platelets, and fibrinogen-have shortcomings that limit their use in providing emergency care. One alternative is to investigate coagulation disturbance with viscoelastic monitoring (VEM), a coagulation test that measures the timing and strength of blood clot development in real time. VEM is widely used and studied in cardiac surgery, liver transplant surgery, anesthesia, and trauma. In this article, we review the technique of VEM and the biologic rationale of using it in addition to routine tests of coagulation in emergency clinical situations. Then, we review the evidence (or lack thereof) for using VEM in the diagnosis and treatment of specific conditions. Finally, we describe the limitations of the test and future directions for clinical use and research in emergency medicine.
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Affiliation(s)
- Patrick D Tyler
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Lauren M Yang
- Department of Medicine, Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Samuel B Snider
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Adam B Lerner
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - William C Aird
- Department of Medicine, Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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80
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Agarwal S, Abdelmotieleb M. Viscoelastic testing in cardiac surgery. Transfusion 2020; 60 Suppl 6:S52-S60. [PMID: 32955756 DOI: 10.1111/trf.16075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
Bleeding complications are common in cardiac surgery and lead to an increase in morbidity and mortality. This is multifactorial in aetiology including the effects of cardiopulmonary bypass, the drugs given to manipulate the coagulation system and the vascular nature of the surgery itself. Viscoelastic tests provide a point of care, rapid assessment of coagulation which offer the advantage of faster turnaround times and a nuanced view of the elements of the coagulation system allowing targeted therapy to be delivered quickly. Both thomboelastography (TEG)and thromboelastometry (ROTEM) have been recommended for use in cardiac surgery, both have shown a reduction in transfusion and bleeding when used as part of a testing algorithm. They are particularly useful in assessing residual heparinisation and fibrinogen levels. Additionally, TEG allows the evaluation of the effects of anti-platelet agents on platelet function. This review discusses the mechanisms by which bleeding occurs in cardiac surgery and explores three uses of viscoelastic testing in cardiac surgery: to predict bleeding, to assess platelet function and peri-operative testing to reduce transfusion.
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Affiliation(s)
- Seema Agarwal
- Department of Cardiothoracic Anaesthesia and ICM, Manchester University Foundation Trust, Manchester, UK
| | - Mohamed Abdelmotieleb
- Department of Cardiothoracic Anaesthesia and ICM, Manchester University Foundation Trust, Manchester, UK
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81
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Adam EH, Fischer D. Plasma Transfusion Practice in Adult Surgical Patients: Systematic Review of the Literature. Transfus Med Hemother 2020; 47:347-359. [PMID: 33173453 DOI: 10.1159/000511271] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/31/2020] [Indexed: 12/18/2022] Open
Abstract
Background Plasma transfusions are most commonly used therapeutically for bleeding or prophylactically in non-bleeding patients prior to invasive procedures or surgery. Although plasma transfusions generally seem to decline, plasma usage for indications that lack evidence of efficacy prevail. Summary There is wide international, interinstitutional, and interindividual variance regarding the compliance with guidelines based on published references, supported by appropriate testing. There is furthermore a profound lack of evidence from randomized controlled trials comparing the effect of plasma transfusion with that of other therapeutic interventions for most indications, including massive bleeding. The expected benefit of a plasma transfusion needs to be balanced carefully against the associated risk of adverse events. In light of the heterogeneous nature of bleeding conditions and their rapid evolvement over time, fibrinogen and factor concentrate therapy, directed at specific phases of coagulation identified by alternative laboratory assays, may offer advantages over conventional blood product ratio-driven resuscitation. However, their outcome benefit has not been demonstrated in well-powered prospective trials. This systematic review will detail the current evidence base for plasma transfusion in adult surgical patients.
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Affiliation(s)
- Elisabeth Hannah Adam
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Dania Fischer
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
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82
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de Vries JJ, Veen CSB, Snoek CJM, Kruip MJHA, de Maat MPM. FIBTEM clot firmness parameters correlate well with the fibrinogen concentration measured by the Clauss assay in patients and healthy subjects. Scandinavian Journal of Clinical and Laboratory Investigation 2020; 80:600-605. [DOI: 10.1080/00365513.2020.1818283] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Judith J. de Vries
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Caroline S. B. Veen
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Charlotte J. M. Snoek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marieke J. H. A. Kruip
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Moniek P. M. de Maat
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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83
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Bolliger D, Tanaka KA. More Is Not Always Better: Effects of Cell Salvage in Cardiac Surgery on Postoperative Fibrinogen Concentrations. J Cardiothorac Vasc Anesth 2020; 34:2383-2385. [DOI: 10.1053/j.jvca.2020.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/19/2020] [Indexed: 12/25/2022]
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84
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Thachil J, Juffermans NP, Ranucci M, Connors JM, Warkentin TE, Ortel TL, Levi M, Iba T, Levy JH. ISTH DIC subcommittee communication on anticoagulation in COVID-19. J Thromb Haemost 2020; 18:2138-2144. [PMID: 32881336 PMCID: PMC7404846 DOI: 10.1111/jth.15004] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 12/22/2022]
Abstract
Hypercoagulability is an increasingly recognized complication of SARS-CoV-2 infection. As such, anticoagulation has become part and parcel of comprehensive COVID-19 management. However, several uncertainties exist in this area, including the appropriate type and dose of heparin. In addition, special patient populations, including those with high body mass index and renal impairment, require special consideration. Although the current evidence is still insufficient, we provide a pragmatic approach to anticoagulation in COVID-19, but stress the need for further trials in this area.
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Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and ICU, IRCCS Policlinico San Donato, San Donato Milanese (Milan, Italy
| | - Jean M Connors
- Hematology Division, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Thomas L Ortel
- Division of Hematology, Departments of Medicine and Pathology, Duke University Medical Center, Durham, NC, USA
| | - Marcel Levi
- Department of Medicine and Cardiometabolic Programme-NIHR UCLH/UCL BRC, University College London Hospitals NHS Foundation Trust London, London, UK
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care and Surgery, Duke University School of Medicine, Durham, NC, USA
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85
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Kitchen DP, Jennings I, Kitchen S, Walker I. Letter in response to article "Systematic review of viscoelastic testing (TEG/Rotem) in obstetrics and recommendations from the women's SSC of the ISTH". J Thromb Haemost 2020; 18:2418-2420. [PMID: 32542986 DOI: 10.1111/jth.14965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 08/31/2023]
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86
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Amgalan A, Allen T, Othman M, Ahmadzia HK. Systematic review of viscoelastic testing (TEG/ROTEM) in obstetrics and recommendations from the women's SSC of the ISTH. J Thromb Haemost 2020; 18:1813-1838. [PMID: 32356929 DOI: 10.1111/jth.14882] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/13/2020] [Accepted: 04/24/2020] [Indexed: 12/13/2022]
Abstract
Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are point-of-care viscoelastic devices that use whole blood samples to assess coagulation and fibrinolysis. These devices have been studied extensively in cardiac surgery, but there is limited robust evidence supporting its use in obstetrics. The hesitancy toward its routine use in obstetrics may be due to the current lack of randomized controlled trials and large observational studies. The study aims to systematically review studies that investigated TEG/ROTEM use in pregnancy or peripartum, and to provide recommendations for future studies to fill current research gaps. We performed a systematic review of studies on viscoelastic testing in obstetrics. Included studies were original research, used TEG or ROTEM during pregnancy or peripartum, and published in English. Ninety-three studies, spanning 31 years from 1989 to 2020 and with a total of 32,817 participants, were included. Sixty-two (66.7%) of the studies used TEG and 31 (33.3%) used ROTEM. To date, there are a total of two randomized controlled trials on TEG/ROTEM use in obstetrics. ROTEM may be used to guide transfusion therapy for postpartum hemorrhage. TEG and ROTEM can detect the hypercoagulable changes associated with pregnancy. Variability between study protocols and results suggests the need for future large prospective high-quality studies with standardized protocols to investigate the utility of TEG/ROTEM in assessing risk for thrombosis and hemorrhage as well as in guiding prophylaxis and treatment in obstetric patients. This review identifies the gaps and provides concrete recommendations for future studies to fill those gaps.
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Affiliation(s)
| | - Terrence Allen
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada
| | - Homa K Ahmadzia
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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87
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Sahli SD, Rössler J, Tscholl DW, Studt JD, Spahn DR, Kaserer A. Point-of-Care Diagnostics in Coagulation Management. SENSORS (BASEL, SWITZERLAND) 2020; 20:E4254. [PMID: 32751629 PMCID: PMC7435714 DOI: 10.3390/s20154254] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/17/2020] [Accepted: 07/28/2020] [Indexed: 12/15/2022]
Abstract
This review provides a comprehensive and up-to-date overview of point-of-care (POC) devices most commonly used for coagulation analyses in the acute settings. Fast and reliable assessment of hemostasis is essential for the management of trauma and other bleeding patients. Routine coagulation assays are not designed to visualize the process of clot formation, and their results are obtained only after 30-90 m due to the requirements of sample preparation and the analytical process. POC devices such as viscoelastic coagulation tests, platelet function tests, blood gas analysis and other coagulometers provide new options for the assessment of hemostasis, and are important tools for an individualized, goal-directed, and factor-based substitution therapy. We give a detailed overview of the related tests, their characteristics and clinical implications. This review emphasizes the evident advantages of the speed and predictive power of POC clot measurement in the context of a goal-directed and algorithm-based therapy to improve the patient's outcome. Interpretation of viscoelastic tests is facilitated by a new visualization technology.
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Affiliation(s)
- Sebastian D. Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - David W. Tscholl
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Jan-Dirk Studt
- Division of Hematology, University and University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
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88
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Zeng X, Fang L, Peng Y, Zhang Y, Li X, Wang Z, Zhang B, Cao Q, Hu X. A multicenter reference interval study of thromboelastography in the Chinese adult population. Thromb Res 2020; 195:180-186. [PMID: 32711234 DOI: 10.1016/j.thromres.2020.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/07/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Imprecise reference intervals (RIs) adversely impact the determination of the need for blood transfusion and clinical diagnosis and treatment of coagulopathy. However, there are few RI studies of thromboelastography (TEG) based on a standard protocol. The present multicenter study aimed to establish RIs for the adult Chinese population. METHODS Healthy participants were recruited from 6 medical centers by non-probability sampling. Blood samples were subjected to laboratory TEG analysis. The Ichihara method, 2-level nested analysis of variance (ANOVA) (2N-ANOVA), and the latent abnormal values exclusion (LAVE) were used to define the RIs following recommendations of the Clinical and Laboratory Standards Institute and International Federation of Clinical Chemistry and Laboratory Medicine, Committee on Reference Intervals and Decision Limits. Multiple regression analysis was performed to explore sources of variation. RESULTS A total of 507 healthy participants were enrolled into the study cohort. Twenty-five individuals with potential coagulopathy were secondarily excluded by LAVE. Smoking was related to reaction time, α angle, and coagulation index in the TEG test (P < 0.05). 2N-ANOVA revealed that the RIs of all 5 test items of TEG needed to be partitioned by age and sex. Finally, TEG RIs were derived both parametrically and nonparametrically for males or females and different age Groups, respectively. CONCLUSIONS TEG RIs were established for the adult Chinese population using up-to-date methodology. The results will provide a useful and essential comparator for patients in the assessment of coagulation state, goal-directed blood transfusion therapy, and monitoring of the pharmacodynamic effects of anticoagulant drugs.
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Affiliation(s)
- Xianfei Zeng
- Department of Laboratory Medicine, Shaanxi Corps Hospital, Chinese People's Armed Police Forces, Xi'an 710054, China; School of Medicine, Northwest University, Xi'an 710069, China; The National Engineering Research Center for Miniaturized Detection Systems, College of Life Science, Northwest University, Xi'an 710069, China
| | - Le Fang
- Department of Laboratory Medicine, 521 Hospital of Ordnance Industry, Xi'an 710065, China
| | - Yongping Peng
- Department of Transfusion Medicine, Xi'an Aerospace General Hospital, Xi'an 710100, China
| | - Yangmin Zhang
- Department of Transfusion Medicine, Xi'an Central Hospital, Xi'an 710003, China
| | - Xiaoyan Li
- Department of Transfusion Medicine, Baoji Central Hospital, Baoji 721008, China
| | - Zhaolong Wang
- Department of Transfusion Medicine, Xi'an Central Hospital, Xi'an 710003, China
| | - Baoping Zhang
- Department of Transfusion Medicine, Xijing Hospital, Xi'an 710032, Fourth Military Medical University, China
| | - Qian Cao
- Department of Laboratory Medicine, Shaanxi Corps Hospital, Chinese People's Armed Police Forces, Xi'an 710054, China
| | - Xingbin Hu
- Department of Transfusion Medicine, Xijing Hospital, Xi'an 710032, Fourth Military Medical University, China.
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89
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Leal-Noval SR, Fernández Pacheco J, Casado Méndez M, Cuenca-Apolo D, Múñoz-Gómez M. Current perspective on fibrinogen concentrate in critical bleeding. Expert Rev Clin Pharmacol 2020; 13:761-778. [PMID: 32479129 DOI: 10.1080/17512433.2020.1776608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION . Massive hemorrhage continues to be a treatable cause of death. Its management varies from prefixed ratio-driven administration of blood components to goal-directed therapy based on point-of-care testing and administration of coagulation factor concentrates. AREAS COVERED . We review the current role of fibrinogen concentrate (FC) for the management of massive hemorrhage, either administered without coagulation testing in life-threatening hemorrhage, or within an algorithm based on viscoelastic hemostatic assays and plasma fibrinogen level. We identified relevant guidelines, meta-analyzes, randomized controlled trials, and observational studies that included indications, dosage, and adverse effects of FC, especially thromboembolic events. EXPERT OPINION . Moderate- to high-grade evidence supports the use of FC for the treatment of severe hemorrhage in trauma and cardiac surgery; a lower grade of evidence is available for its use in postpartum hemorrhage and end-stage liver disease. Pre-emptive FC administration in non-bleeding patients is not recommended. FC should be administered early, in a goal-directed manner, guided by early amplitude of clot firmness parameters (A5- or A10-FIBTEM) or hypofibrinogenemia. Further investigation is required into the early use of FC, as well as its potential advantages over cryoprecipitate, and whether or not its administration at high doses leads to a greater risk of adverse events.
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Affiliation(s)
- Santiago R Leal-Noval
- Neuro Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Jose Fernández Pacheco
- Pharmacy and Statistics and Design, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Casado Méndez
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Diego Cuenca-Apolo
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Múñoz-Gómez
- Department of Surgical Specialties, Biochemistry and Immunology, University of Málaga , 29071, Málaga, Spain
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90
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Agarwal S, Laycock HC. The debate ROTEMs on - the utility of point-of-care testing and fibrinogen concentrate in postpartum haemorrhage. Anaesthesia 2020; 75:1247-1251. [PMID: 32662889 DOI: 10.1111/anae.15193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2020] [Indexed: 11/29/2022]
Affiliation(s)
- S Agarwal
- Department of Cardiothoracic Anaesthesia and Critical Care, Manchester Royal Infirmary, Manchester, UK
| | - H C Laycock
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
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91
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Haemostatic function measured by thromboelastography and metabolic activity of platelets treated with riboflavin and UV light. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:280-289. [PMID: 32530405 DOI: 10.2450/2020.0314-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/20/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Pathogen reduction technology (PRT) may damage platelet (PLT) components. To study this, metabolic activity and haemostatic function of buffy coat (BC) PLT concentrates, with or without riboflavin and UV light PRT treatment, were compared. MATERIAL AND METHODS Twenty-four BC PLT concentrates, leukoreduced and diluted in additive solution, were grouped into 12 type-matched pairs, which were pooled and divided into 12 non-PRT-treated BC PLT concentrates (control units) and 12 riboflavin and UV PRT-treated BC PLT concentrates (test units). Haemostatic function and metabolic parameters were monitored by thrombelastography at days 1, 3, 7 and 14 post collection in both PLT groups. RESULTS Loss of PLT discoid shape, glucose consumption, lactate production, and decrease in pH were greater in the PRT-treated PLTs than in control PLTs over time (p<0.001). PLT haemostatic function evaluated by clot strength was also significantly weaker in PRT-treated PLTs compared with the excellent clot quality of control PLTs at day 7 (maximum amplitude: 41.27 vs 64.27; p<0.001), and even at day 14 (21.16 vs 60.39; p<0.001) of storage. DISCUSSION Pathogen reduction technology treatment accelerates and increases platelet storage lesion, resulting in glucose depletion, lactate accumulation, PLT acidification, and discoid shape loss. The clots produced by control PLTs at day 14 were still remarkably strong, whereas at day 7 PRT-treated PLTs produced weaker clots compared to the control group. Clinical trials investigating the efficacy of PRT-treated PLTs transfused at the end of the storage period (day 7), when the in vitro clot strength is weaker, are needed.
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92
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Scorer TG, FitzGibbon L, Aungraheeta R, Sharma U, Peltier GC, McIntosh CS, Reddoch-Cardenas KM, Meyer A, Cap AP, Mumford AD. TEG PlateletMapping assay results may be misleading in the presence of cold stored platelets. Transfusion 2020; 60 Suppl 3:S119-S123. [PMID: 32478898 DOI: 10.1111/trf.15753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/28/2020] [Accepted: 02/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Viscoelastic tests (VETs) are used widely to monitor hemostasis in settings such as cardiac surgery. There has also been renewed interest in cold stored platelets (CSPs) to manage bleeding in this setting. CSPs are reported to have altered hemostatic properties compared to room temperature platelets (RTPs), including activation of GPIIb/IIIa. We investigated whether the functional differences between CSP and RTP affected the performance of the PlateletMapping VET on the TEG 5000 and 6s analyzer. METHOD Platelet concentrates were divided equally into CSP (stored at 4°C ± 2°C) and RTP (stored at 22°C ± 2°C) fractions. Whole blood was treated to induce platelet dysfunction (WBIPD) by incubating with anti-platelet drugs (1.0 μM ticagrelor and 10 μM aspirin) or by simulating cardiopulmonary bypass. WBIPD samples were then mixed with 20% by volume of CSPs or RTPs to model platelet transfusion before analysis using the PlateletMapping VET. RESULTS Addition of CSPs to WBIPD increased the PlateletMapping MAFIBRIN and MAADP parameters with the TEG 5000 analyzer (both p < 0.0001 compared to addition of buffer alone). This effect was not observed with RTPs. The differential effect of CSPs on the MAFIBRIN corrected after pre-incubation with the GPIIb/IIIa antagonist tirofiban and was quantitatively less with the PlateletMapping test for the TEG 6s analyzer which contains the GPIIb/IIa antagonist abciximab. DISCUSSION The PlateletMapping MAFIBRIN and MAADP test results may be misleadingly high with CSPs, particularly with the TEG 5000 analyzer, most likely due to constitutive activation of GPIIb/IIIa on CSPs during storage. TEG PlateletMapping results should be interpreted with caution following CSP transfusion.
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Affiliation(s)
- Thomas G Scorer
- Centre of Defence Pathology, Royal Centre of Defence Medicine, Birmingham, UK.,School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK.,Coagulation and Blood Research, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Lucy FitzGibbon
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Riyaad Aungraheeta
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Umang Sharma
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Grantham C Peltier
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Colby S McIntosh
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | | | - Andrew Meyer
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA.,Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Andrew P Cap
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas, USA
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
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93
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Leitner GC, Ho M, Tolios A, Hopfinger G, Rabitsch W, Wohlfarth P. The assessment of platelet function by thromboelastometry as a point-of-care test to guide Intercept-treated platelet support in hemato-oncological patients and hematopoietic stem cell transplantation recipients. Transfusion 2020; 60:1391-1399. [PMID: 32319678 PMCID: PMC7497158 DOI: 10.1111/trf.15783] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 03/04/2020] [Accepted: 03/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pathogen inactivation (PI) techniques for platelet concentrates (PCs) are one of the latest innovations to improve blood safety and reduce the risk of transfusion‐transmitted infections (TTIs). An impaired function and in vivo recovery of platelets as well as an increased PC demand are concerns regarding these techniques. The intent of this study was to evaluate the hemostatic effect of PCs treated with the Intercept™ System by thromboelastometry (TEM) and to assess the clinical validity of its results in comparison to post‐transfusion increase (PTI) and corrected count increment (CCI). STUDY‐DESIGN AND METHODS This prospective‐observational study included 47 patients (m:f = 25:22; median age: 54 years [21‐70]) of our Bone Marrow Transplantation unit with hemato‐oncological malignancies transfused with Intercept™‐treated PCs. Serial TEM measurements were performed just before and 1 hour after PC transfusion and were analyzed for their correlation with PTI and CCI as well as for clinical variables. RESULTS The majority of our patients had received a hematopoietic stem cell transplantation (HSCT) (n = 41; 87%). In median 9 (1‐50) PCs were transfused. Serial TEM, PTI, and CCI measurements were available for 150 transfusion episodes. The median platelet dose transfused was 2.65 × 1011/unit (1.8‐6). The median CCI was 9.250 (0‐28.000). We observed a significant improvement in TEM parameters (p < 0.05) after transfusion of PI PCs, which did not mandatory correlate with the 1‐hour PTI and CCI. CONCLUSION Serial TEM measurements indicate the hemostatic effect of Intercept™‐treated PCs. The 1‐hour PTI and CCI may not appropriately reflect the in vivo function of platelets after PI PC transfusion.
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Affiliation(s)
- Gerda C Leitner
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Ho
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Alexander Tolios
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Georg Hopfinger
- Stem Cell Transplantation Unit, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Werner Rabitsch
- Stem Cell Transplantation Unit, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Philipp Wohlfarth
- Stem Cell Transplantation Unit, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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94
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Multicenter Evaluation of the Quantra QPlus System in Adult Patients Undergoing Major Surgical Procedures. Anesth Analg 2020; 130:899-909. [DOI: 10.1213/ane.0000000000004659] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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95
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Warhadapande S, Dariushnia SR, Kokabi N, O'Connell WG, Newsome JM, Findeiss LK, Majdalany BS. Clinical Approach to and Work-up of Bleeding Patients. Semin Intervent Radiol 2020; 37:24-30. [PMID: 32139967 DOI: 10.1055/s-0039-3402017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A bleeding patient is a common consult for interventional radiologists. Prompt triage, preprocedural evaluation specific to the site of hemorrhage, and knowledge of resuscitative strategies allow for a potentially life-saving procedure to be appropriately and safely performed. Having a firm understanding of the clinical work-up and management of a bleeding patient has never been more important. In this article, a discussion of the clinical approach and work-up of a bleeding patient for whom interventional radiology is consulted is followed by a discussion of etiology-specific preprocedural work-up.
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Affiliation(s)
- Shantanu Warhadapande
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sean R Dariushnia
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Nima Kokabi
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - William G O'Connell
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Janice M Newsome
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Laura K Findeiss
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
| | - Bill S Majdalany
- Division of Vascular and Interventional Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, Georgia
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96
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Thrombin generation and bleeding in cardiac surgery: a clinical narrative review. Can J Anaesth 2020; 67:746-753. [PMID: 32133581 DOI: 10.1007/s12630-020-01609-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 12/27/2022] Open
Abstract
This narrative review discusses the role of thrombin generation in coagulation and bleeding in cardiac surgery, the laboratory methods for clinical detection of impaired thrombin generation, and the available hemostatic interventions that can be used to improve thrombin generation. Coagulopathy after cardiopulmonary bypass (CPB) is associated with excessive blood loss and adverse patient outcomes. Thrombin plays a crucial role in primary hemostasis, and impaired thrombin generation can be an important cause of post-CPB coagulopathy. Existing coagulation assays have significant limitations in assessing thrombin generation, but whole-blood assays designed to measure thrombin generation at the bed-side are under development. Until then, clinicians may need to institute therapy empirically for non-surgical bleeding in the setting of normal coagulation measures. Available therapies for impaired thrombin generation include administration of plasma, prothrombin complex concentrate, and bypassing agents (recombinant activated factor VII and factor eight inhibitor bypassing activity). In vitro experiments have explored the relative potency of these therapies, but clinical studies are lacking. The potential incorporation of thrombin generation assays into clinical practice and treatment algorithms for impaired thrombin generation must await further clinical development.
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97
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Hartmann J, Murphy M, Dias JD. Viscoelastic Hemostatic Assays: Moving from the Laboratory to the Site of Care-A Review of Established and Emerging Technologies. Diagnostics (Basel) 2020; 10:diagnostics10020118. [PMID: 32098161 PMCID: PMC7167835 DOI: 10.3390/diagnostics10020118] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 11/16/2022] Open
Abstract
Viscoelastic-based techniques to evaluate whole blood hemostasis have advanced substantially since they were first developed over 70 years ago but are still based upon the techniques first described by Dr. Hellmut Hartert in 1948. Today, the use of thromboelastography, the method of testing viscoelastic properties of blood coagulation, has moved out of the research laboratory and is now more widespread, used commonly during surgery, in emergency departments, intensive care units, and in labor wards. Thromboelastography is currently a rapidly growing field of technological advancement and is attracting significant investment. This review will first describe the history of the viscoelastic testing and the established first-generation devices, which were developed for use within the laboratory. This review will then describe the next-generation hemostasis monitoring devices, which were developed for use at the site of care for an expanding range of clinical applications. This review will then move on to experimental technologies, which promise to make viscoelastic testing more readily available in a wider range of clinical environments in the endeavor to improve patient care.
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Affiliation(s)
- Jan Hartmann
- Haemonetics Corporation, Boston, MA 02110, USA;
- Correspondence: ; Tel.: +1-781-348-7396
| | | | - Joao D. Dias
- Haemonetics SA, Signy CH, 1274 Signy-Centre, Switzerland;
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98
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Dhara S, Moore EE, Yaffe MB, Moore HB, Barrett CD. Modern Management of Bleeding, Clotting, and Coagulopathy in Trauma Patients: What Is the Role of Viscoelastic Assays? CURRENT TRAUMA REPORTS 2020; 6:69-81. [PMID: 32864298 DOI: 10.1007/s40719-020-00183-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose of Review The purpose of this review is to briefly outline the current state of hemorrhage control and resuscitation in trauma patients with a specific focus on the role viscoelastic assays have in this complex management, to include indications for use across all phases of care in the injured patient. Recent Findings Viscoelastic assay use to guide blood-product resuscitation in bleeding trauma patients can reduce mortality by up to 50%. Viscoelastic assays also reduce total blood products transfused, reduce ICU length of stay, and reduce costs. There are a large number of observational and retrospective studies evaluating viscoelastic assay use in the initial trauma resuscitation, but only one randomized control trial. There is a paucity of data evaluating use of viscoelastic assays in the operating room, post-operatively, and during ICU management in trauma patients, rendering their use in these settings extrapolative/speculative based on theory and data from other surgical disciplines and settings. Summary Both hypocoagulable and hypercoagulable states exist in trauma patients, and better indicate what therapy may be most appropriate. Further study is needed, particularly in the operating room and post-operative/ICU settings in trauma patients.
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Affiliation(s)
- Sanjeev Dhara
- University of Chicago School of Medicine, Chicago, IL
| | - Ernest E Moore
- Department of Surgery, University of Colorado Denver, Denver, CO
| | - Michael B Yaffe
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Denver, CO
| | - Christopher D Barrett
- Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, MA
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99
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Shah A, Palmer AJR, Klein AA. Strategies to minimize intraoperative blood loss during major surgery. Br J Surg 2020; 107:e26-e38. [DOI: 10.1002/bjs.11393] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies.
Methods
This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient.
Results
Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays.
Conclusion
Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.
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Affiliation(s)
- A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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100
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The utility of thromboelastography and tranexamic acid in plasminogen activator inhibitor deficiency during pregnancy: a rare case report. Blood Coagul Fibrinolysis 2020; 31:87-91. [DOI: 10.1097/mbc.0000000000000869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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