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Abstract
A variety of point-of-care monitors for the measurement of hematocrit, hemoglobin, blood gas with electrolytes, and lactate can be used also in the prehospital setting for optimizing and individualizing trauma resuscitation. Point-of-care coagulation testing with activated prothrombin test, prothrombin test, and activated coagulation/clotting time tests is available for prehospital use. Although robust, battery driven, and easy to handle, many devices lack documentation for use in prehospital care. Some of the devices correspond poorly to corresponding laboratory analyses in acute trauma coagulopathy and at lower hematocrits. In trauma, viscoelastic tests such as rotational thromboelastometry and thromboelastography can rapidly detect acute trauma coagulopathy and give an overall dynamic picture of the hemostatic system and the interaction between its different components: coagulation activation, fibrin polymerization, fibrin platelet interactions within the clot, and fibrinolysis. Rotational thromboelastometry is shock resistant and has the potential to be used outside the hospital setting to guide individualized coagulation factor and blood component therapies. Sonoclot and Rheorox are two small viscoelastic instruments with one-channel options, but with less documentation. The point-of-care market for coagulation tests is quickly expanding, and new devices are introduced all the time. Still they should be better adopted to prehospital conditions, small, robust, battery charged, and rapid and use small sample volumes and whole blood.
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Besser MW, Ortmann E, Klein AA. Haemostatic management of cardiac surgical haemorrhage. Anaesthesia 2014; 70 Suppl 1:87-95, e29-31. [DOI: 10.1111/anae.12898] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2014] [Indexed: 11/28/2022]
Affiliation(s)
- M. W. Besser
- Department of Haematology; Papworth Hospital; Cambridge UK
| | - E. Ortmann
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
- Department of Anaesthesia and Intensive Care; Kerckhoff Klinik Heart and Lung Centre; Bad Nauheim Germany
| | - A. A. Klein
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
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Management of severe bleeding in a ruptured extrauterine pregnancy: a theragnostic approach. Blood Coagul Fibrinolysis 2014; 25:176-9. [PMID: 24253241 DOI: 10.1097/mbc.0000000000000010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Haemoperitoneum due to ruptured extrauterine pregnancy is a complication that may occur in the first trimester of pregnancy, but massive haemorrhage with severe shock is rare. When severe bleeding does occur, timely diagnosis and rapid haemostatic treatment are vital. We present the case of a 37-year-old woman with severe bleeding and shock due to ruptured extrauterine pregnancy.Management of the patient consisted of emergency laparotomy, red blood cell transfusion and targeted haemostatic therapy guided by rotational thromboelastometry using the fibrin-based clotting (FIBTEM) assay, (activation with tissue factor with addition of the platelet inhibitor cytochalasin D). As severe hypofibrinogenaemia was apparent, indicated by a FIBTEM maximum clot firmness (MCF) that was not measurable (i.e. < 2 mm) and a plasma fibrinogen level of 0.17 g/l, the patient was treated with 4 g fibrinogen concentrate. Tranexamic acid (1 g) was also administered.Rapid restoration of haemostasis was indicated by the improvement of thromboelastometric parameters (FIBTEM MCF 16 mm) and, later, laboratory coagulation tests (plasma fibrinogen 2.75 g/l), along with cessation of bleeding. No fresh frozen plasma (FFP) was administered. Surgery was successfully completed, and the patient was subsequently discharged 5 days after admission with no further complications. Haemorrhage in extrauterine pregnancy is commonly managed using autologous blood transfusion (via cell salvage) and homologous plasma transfusion. In this case of severe bleeding and shock due to ruptured extrauterine pregnancy, thromboelastometry-guided administration of fibrinogen concentrate enabled rapid restoration of haemostasis, complete avoidance of FFP transfusion and resulted in a successful outcome.
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Fibrinogen Concentrate Does Not Suppress Endogenous Fibrinogen Synthesis in a 24-hour Porcine Trauma Model. Anesthesiology 2014; 121:753-64. [DOI: 10.1097/aln.0000000000000315] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background:
Fibrinogen concentrate may reduce blood loss after trauma. However, its effect on endogenous fibrinogen synthesis is unknown. The authors investigated the effect of exogenous human fibrinogen on endogenous fibrinogen metabolism in a 24-h porcine trauma model.
Methods:
Coagulopathy was induced in 20 German Landrace pigs by hemodilution and blunt liver injury. Animals were randomized to receive fibrinogen concentrate (100 mg/kg; infusion beginning 20 min postinjury and lasting approximately 10 min) or saline. Fibrinogen concentration, thromboelastometry, and quantitative reverse transcriptase polymerase chain reaction of fibrinogen genes in liver tissue samples were recorded. Internal organs were examined histologically for emboli.
Results:
Coagulation parameters were impaired and plasma fibrinogen concentrations were reduced before starting infusion of fibrinogen concentrate/saline. Twenty minutes after starting infusion, exogenous fibrinogen supplementation had increased plasma fibrinogen concentration versus controls (171 ± 19 vs. 63 ± 10 mg/dl [mean ± SD for Multifibren U]; 185 ± 30 vs. 41 ± 4 mg/dl [Thrombin reagent]; P < 0.05 for both comparisons). The between-group difference in plasma fibrinogen concentration diminished thereafter, with maximum concentrations in both groups observed at approximately 24 h, that is, during the acute-phase reaction after trauma. Fibrinogen supplementation did not down-regulate endogenous fibrinogen synthesis (no between-group differences in fibrinogen messenger RNA). Total postinjury blood loss was significantly lower in the fibrinogen group (1,062 ± 216 vs. 1,643 ± 244 ml; P < 0.001). No signs of thromboembolism were observed.
Conclusions:
Administration of human fibrinogen concentrate did not down-regulate endogenous porcine fibrinogen synthesis. The effect on plasma fibrinogen concentration was most pronounced at 20 min but nonsignificant at approximately 24 h.
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Shams Hakimi C, Fagerberg Blixter I, Hansson EC, Hesse C, Wallén H, Jeppsson A. Effects of fibrinogen and platelet supplementation on clot formation and platelet aggregation in blood samples from cardiac surgery patients. Thromb Res 2014; 134:895-900. [DOI: 10.1016/j.thromres.2014.05.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 05/02/2014] [Accepted: 05/16/2014] [Indexed: 10/25/2022]
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Plasma fibrinogen level on admission to the intensive care unit is a powerful predictor of postoperative bleeding after cardiac surgery with cardiopulmonary bypass. Thromb Res 2014; 134:360-8. [DOI: 10.1016/j.thromres.2014.05.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 04/23/2014] [Accepted: 05/07/2014] [Indexed: 11/22/2022]
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Plasma fibrinogen concentration is correlated with postoperative blood loss in children undergoing cardiac surgery. Eur J Anaesthesiol 2014; 31:317-26. [DOI: 10.1097/eja.0000000000000043] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Estcourt LJ, Stanworth SJ, Harrison P, Powter G, McClure M, Murphy MF, Mumford AD. Prospective observational cohort study of the association between thromboelastometry, coagulation and platelet parameters and bleeding in patients with haematological malignancies- The ATHENA study. Br J Haematol 2014; 166:581-91. [DOI: 10.1111/bjh.12928] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 03/24/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Lise J. Estcourt
- NHS Blood and Transplant; Oxford UK
- Radcliffe Department of Medicine; University of Oxford; Oxford UK
| | - Simon J. Stanworth
- NHS Blood and Transplant; Oxford UK
- Radcliffe Department of Medicine; University of Oxford; Oxford UK
| | - Paul Harrison
- School of Immunity and Infection; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
| | | | - Marianne McClure
- Haematology Department; University of Oxford Hospitals NHS Trust; Oxford UK
| | - Michael F. Murphy
- NHS Blood and Transplant; Oxford UK
- Radcliffe Department of Medicine; University of Oxford; Oxford UK
| | - Andrew D. Mumford
- School of Cellular and Molecular Medicine; University of Bristol; Bristol UK
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Schlimp CJ, Solomon C, Ranucci M, Hochleitner G, Redl H, Schöchl H. The effectiveness of different functional fibrinogen polymerization assays in eliminating platelet contribution to clot strength in thromboelastometry. Anesth Analg 2014; 118:269-276. [PMID: 24445628 DOI: 10.1213/ane.0000000000000058] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Viscoelastic tests such as functional fibrinogen polymerization assays (FFPAs) in thrombelastography (TEG®) or thromboelastometry (ROTEM®) measure clot elasticity under platelet inhibition. Incomplete platelet inhibition influences maximum clot firmness (MCF) of FFPAs. We compared the ability of existing and newly developed FFPAs to eliminate the platelet contribution to clot strength. METHODS MCF of whole blood (WB), platelet-rich plasma (PRP), and platelet-poor plasma samples was recorded using a ROTEM device with different FFPAs, including the TEG functional fibrinogen test (FFTEG) and different ROTEM-based assays: the standard fib-tem reagent (FIBTEM), a lyophilized single-portion reagent fib-tem S (FIBTEM-S), a newly developed reagent FIBTEM PLUS, as well as FIBTEM or the standard extrinsic activation reagent ex-tem® (EXTEM) combined with 10-μg abciximab (FIBTEM-ABC/EXTEM-ABC). RESULTS In WB (platelet count [mean ± SD], 183 ± 37 × 10/μL; plasma fibrinogen concentration, 2.49 ± 0.58 g/L), FFTEG and EXTEM-ABC showed higher MCF (15.7 ± 2.8 mm) than FIBTEM or FIBTEM-S (11.4 ± 3.3 mm, P < 0.001), whereas FIBTEM-ABC and FIBTEM PLUS resulted in lower MCF (9.3 ± 2.8 mm, P < 0.001). In 2 different PRP samples, with platelet counts of 407 ± 80 × 10/μL and 609 ± 127 × 10/μL, FIBTEM-ABC and FIBTEM PLUS reduced platelet contribution to clot strength within 95% confidence interval limits of -1.4 to 0.1 mm and -1.2 to 0.4 mm, respectively. Using all FFPAs it was observed that the Pearson correlation coefficient between plasma fibrinogen concentration and WB MCF was high (range, 0.75-0.93) and significant, regardless of the underlying platelet inhibiting component. Evaluating differences in the interception of regression lines by using analysis of covariance, we compared platelet-poor plasma and both PRP samples within the same assays and found that in contrast to the FIBTEM-ABC and FIBTEM PLUS assays, the FFTEG, EXTEM-ABC, FIBTEM, and FIBTEM-S methods still detected residual platelet activity and grossly overestimated fibrin clot strength in samples with high platelet counts. CONCLUSIONS FFPAs based solely on glycoprotein-IIb/IIIa inhibition, such as FFTEG or EXTEM-ABC, are less effective than cytochalasin D-based assays, such as FIBTEM or FIBTEM-S, at inhibiting the platelet component of clot strength. The FIBTEM PLUS assay, and the combination of FIBTEM and abciximab, sufficiently inhibits platelet contribution to clot elasticity. The combination of a glycoprotein-IIb/IIIa receptor blocker and cytochalasin D allows evaluation of functional fibrinogen polymerization without platelet "noise." In a clinical setting, the significance of potent platelet inhibition ensures a more accurate assessment of MCF and therefore the need for fibrinogen supplementation therapy. Further studies are necessary to investigate the application and impact of these tests in a clinical situation.
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Affiliation(s)
- Christoph J Schlimp
- From the Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna; Department of Anesthesiology and Intensive Care, Salzburger Landeskliniken SALK, Salzburg, Austria; CSL Behring, Marburg, Germany; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy; and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Salzburg, Austria
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Solomon C, Baryshnikova E, Schlimp CJ, Schöchl H, Asmis LM, Ranucci M. FIBTEM PLUS provides an improved thromboelastometry test for measurement of fibrin-based clot quality in cardiac surgery patients. Anesth Analg 2013; 117:1054-62. [PMID: 24108255 DOI: 10.1213/ane.0b013e3182a1afac] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The viscoelastic functional fibrinogen (FF) and FIBTEM assays measure the contribution of fibrin to clot strength. Inhibition of platelet function is a necessary precondition for these tests to work. We investigated a novel test for measuring fibrin-based clotting, FIBTEM PLUS, in cardiac surgery and compared it with FF and FIBTEM. METHODS A prospective, observational study was performed which included 30 patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Blood samples were drawn at the beginning of surgery (pre-CPB), approximately 20 minutes before weaning from CPB and 5 minutes after heparin neutralization. FF, FIBTEM, and FIBTEM PLUS tests were performed in duplicate for all blood samples. Additional coagulation parameters, including platelet count, plasma fibrinogen levels, factor XIII activity, and heparin concentration, were also recorded for each sample. RESULTS At all time points, the lowest mean maximum clot firmness (MCF) was observed with FIBTEM PLUS, although a statistically significant difference between FIBTEM and FIBTEM PLUS was observed only at baseline (mean values 22 vs 19 mm, P = 0.01; FF value for comparison: 27.7 mm). FF maximum amplitude (MA) values were significantly higher than FIBTEM MCF and FIBTEM PLUS MCF pre-CPB, during CPB and after heparin neutralization (P ≤ 0.001 for FF MA versus FIBTEM MCF and for FF MA versus FIBTEM PLUS MCF at all time points). The difference between FIBTEM MCF and FIBTEM PLUS MCF correlated with platelet count (r = 0.46;P < 0.001), whereas differences between FF MA and FIBTEM MCF, or FF MA and FIBTEM PLUS MCF did not (r = -0.07, P = 0.51; r = 0.16, P = 0.12, respectively). Differences between the assays were unrelated to heparin levels, which decreased considerably after protamine administration compared with heparin levels recorded before weaning from CPB (decrease from 2.1 to 0.1 U/mL and from 2.8 to 0.2 U/mL for anti-factor IIa and anti-factor Xa, respectively). Agreement between duplicate measurements was similar with FIBTEM and FIBTEM PLUS assays and lower with FF. Significant positive correlations were found between MCF or MA and fibrinogen concentration (all P < 0.001); the highest correlation was with FIBTEM PLUS MCF (r = 0.70). CONCLUSION The FIBTEM PLUS assay produces precise results. At baseline, it provides greater inhibition of platelets than FIBTEM, but there is no meaningful difference between FIBTEM PLUS and FIBTEM in patients with low platelet counts.
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Affiliation(s)
- Cristina Solomon
- From the *Department of Anesthesiology and Intensive Care, Salzburger Landeskliniken SALK, Salzburg, Austria; †CSL Behring, Marburg, Germany; ‡Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy; §Haemostasis Research, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; ‖Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Salzburg, Austria; and ¶Laboratory Medicine, Unilabs Coagulation Laboratory, Zurich, Switzerland
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Elliott BM, Aledort LM. Restoring hemostasis: fibrinogen concentrate versus cryoprecipitate. Expert Rev Hematol 2013; 6:277-86. [PMID: 23782082 DOI: 10.1586/ehm.13.22] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Fibrinogen plays a key role in the coagulation process, and therefore maintaining adequate quantities of fibrinogen is an essential step in achieving satisfactory hemostasis in patients with acquired hypofibrinogenemia. Potential options for treating acquired hypofibrinogenemia in patients with uncontrolled bleeding include the use of cryoprecipitate or fibrinogen replacement therapy. This review provides a brief overview of the hemostatic process and the methods for assessing coagulopathy and discusses the efficacy and safety of cryoprecipitate and fibrinogen concentrate in restoring fibrinogen levels, achieving hemostasis and reducing transfusion requirements in different patient populations requiring rapid hemostasis. Other issues relevant to the clinical use of these agents in restoring hemostasis, including variations in product composition, preparation time and cost, are also examined.
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Affiliation(s)
- Brian M Elliott
- Division of Hematology/Oncology, Mount Sinai Medical Center, One Gustave L Levy Place, Box 1079, NY 10029, USA.
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Tanaka K, Esper S, Bolliger D. Perioperative factor concentrate therapy. Br J Anaesth 2013; 111 Suppl 1:i35-49. [DOI: 10.1093/bja/aet380] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Lee SH, Lee SM, Kim CS, Cho HS, Lee JH, Lee CH, Kim E, Sung K, Solomon C, Kang J, Kim YR. Fibrinogen recovery and changes in fibrin-based clot firmness after cryoprecipitate administration in patients undergoing aortic surgery involving deep hypothermic circulatory arrest. Transfusion 2013; 54:1379-87. [DOI: 10.1111/trf.12479] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 08/08/2013] [Accepted: 09/13/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine; Dongtan Sacred Heart Hospital; Hallym University College of Medicine; Hwasung City Gyunggi do Republic of Korea
- Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Sangmin M. Lee
- Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Chung Su Kim
- Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Hyun Sung Cho
- Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Cheol Hee Lee
- Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Eunhee Kim
- Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Cristina Solomon
- Department of Anesthesiology, Perioperative Medicine and General Intensive Care; SALK University Hospital; Salzburg Austria
- CSL Behring GmbH; Marburg Germany
| | - Jingu Kang
- Department of Anesthesiology and Pain Medicine; Dongtan Sacred Heart Hospital; Hallym University College of Medicine; Hwasung City Gyunggi do Republic of Korea
| | - Young Ri Kim
- Department of Anesthesiology and Pain Medicine; Dongtan Sacred Heart Hospital; Hallym University College of Medicine; Hwasung City Gyunggi do Republic of Korea
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Schlimp CJ, Voelckel W, Inaba K, Maegele M, Ponschab M, Schöchl H. Estimation of plasma fibrinogen levels based on hemoglobin, base excess and Injury Severity Score upon emergency room admission. Crit Care 2013; 17:R137. [PMID: 23849249 PMCID: PMC4056007 DOI: 10.1186/cc12816] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 05/24/2013] [Accepted: 07/12/2013] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Fibrinogen plays a key role in hemostasis and is the first coagulation factor to reach critical levels in massively bleeding trauma patients. Consequently, rapid estimation of plasma fibrinogen (FIB) is essential upon emergency room (ER) admission, but is not part of routine coagulation monitoring in many centers. We investigated the predictive ability of the laboratory parameters hemoglobin (Hb) and base excess (BE) upon admission, as well as the Injury Severity Score (ISS), to estimate FIB in major trauma patients. METHODS In this retrospective study, major trauma patients (ISS ≥16) with documented FIB analysis upon ER admission were eligible for inclusion. FIB was correlated with Hb, BE and ISS, alone and in combination, using regression analysis. RESULTS A total of 675 patients were enrolled (median ISS 27). FIB upon admission correlated strongly with Hb, BE and ISS. Multiple regression analysis showed that Hb and BE together predicted FIB (adjusted R2 = 0.46; loge(FIB) = 3.567 + 0.223.Hb - 0.007.Hb2 + 0.044.BE), and predictive strength increased when ISS was included (adjusted R2 = 0.51; loge(FIB) = 4.188 + 0.243.Hb - 0.008.Hb2 + 0.036.BE - 0.031.ISS + 0.0003.ISS2). Of all major trauma patients admitted with Hb <12 g/dL, 74% had low (<200 mg/dL) FIB and 54% had critical (<150 mg/dL) FIB. Of patients admitted with Hb <10 g/dL, 89% had low FIB and 73% had critical FIB. These values increased to 93% and 89%, respectively, among patients with an admission Hb <8 g/dL. Sixty-six percent of patients with only a weakly negative BE (<-2 mmol/L) showed low FIB. Of patients with BE <-6 mmol/L upon admission, 81% had low FIB and 63% had critical FIB. The corresponding values for BE <-10 mmol/L were 89% and 78%, respectively. CONCLUSIONS Upon ER admission, FIB of major trauma patients shows strong correlation with rapidly obtainable, routine laboratory parameters such as Hb and BE. These two parameters might provide an insightful and rapid tool to identify major trauma patients at risk of acquired hypofibrinogenemia. Early calculation of ISS could further increase the ability to predict FIB in these patients. We propose that FIB can be estimated during the initial phase of trauma care based on bedside tests.
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Affiliation(s)
- Christoph J Schlimp
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Wolfgang Voelckel
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre, Dr. Franz Rehrl Platz 5, 5020 Salzburg, Austria
| | - Kenji Inaba
- Department of Surgery, Los Angeles County and University of Southern California Medical Center, 2051 Marengo Street, Los Angeles, CA 90033, USA
| | - Marc Maegele
- Department of Trauma and Orthopedic Surgery, Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Ostmerheimerstrasse 200, 51109 Cologne, Germany
| | - Martin Ponschab
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre, Garnisonstrasse 7, 4017 Linz, Austria
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre, Dr. Franz Rehrl Platz 5, 5020 Salzburg, Austria
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Schlimp CJ, Solomon C, Hochleitner G, Zipperle J, Redl H, Schöchl H. Thromboelastometric Maximum Clot Firmness in Platelet-Free Plasma Is Influenced by the Assay Used. Anesth Analg 2013; 117:23-9. [DOI: 10.1213/ane.0b013e3182937b91] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Tanaka KA, Egan K, Szlam F, Ogawa S, Roback JD, Sreeram G, Guyton RA, Chen EP. Transfusion and hematologic variables after fibrinogen or platelet transfusion in valve replacement surgery: preliminary data of purified lyophilized human fibrinogen concentrate versus conventional transfusion. Transfusion 2013; 54:109-18. [DOI: 10.1111/trf.12248] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 03/31/2013] [Accepted: 04/01/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Kenichi A. Tanaka
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Katherine Egan
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Fania Szlam
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Satoru Ogawa
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - John D. Roback
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Gautam Sreeram
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Robert A. Guyton
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Edward P. Chen
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
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von Bormann B, Suksompong S, Zander R. Therapy with fibrinogen concentrate: clinical and ethical considerations. Transfusion 2013; 53:1137-8. [PMID: 23659528 DOI: 10.1111/trf.12113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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DIRKMANN D, GÖRLINGER K, DUSSE F, KOTTENBERG E, PETERS J. Early thromboelastometric variables reliably predict maximum clot firmness in patients undergoing cardiac surgery: a step towards earlier decision making. Acta Anaesthesiol Scand 2013; 57:594-603. [PMID: 23240733 DOI: 10.1111/aas.12040] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND While much effort has been spent on guiding coagulation and transfusion therapy in patients undergoing cardiopulmonary bypass (CPB) surgery, the use of conventional laboratory-based coagulation tests is hampered by long turnaround times and interference with heparin and protamine. To allow faster assessment of maximum clot firmness (MCF) by point-of-care thromboelastometry (ROTEM®, TEM International GmbH, Munich, Germany), we tested whether clotting time (CT), clot formation time (CFT), or early values of clot firmness (CF) predict MCF. METHODS Results of 437 ROTEM® assays (EXTEM®, INTEM®, FIBTEM®, and HEPTEM®) from 84 patients undergoing CPB surgery were analyzed. Measurements were performed prior to and after heparin administration, as well as after protamine administration and CT, CFT, and CF after 5, 10, and 15 min (A5, A10, and A15) after initial clotting (CT) were related to MCF. STATISTICS Regression and Bland-Altman analyses and receiver-operating characteristics (ROCs). RESULTS CFT (r = 0.87-0.95), A5 (r = 0.84-0.98; P < 0.0001), A10 (r = 0.86-0.98; P < 0.0001), and A15 (r = 0.86-0.98; P < 0.0001) demonstrated high correlation coefficients with MCF, whereas CT correlated weakly (r = 0.07-0.41). As expected, correlation coefficients increased with the time allowed to assess a specific variable. ROC analyses demonstrated excellent accuracy for CFT, A5, A10, and A15 [area under the curve (AUC): 0.9476-0.9931] to predict a subnormal MCF, whereas CT demonstrated poor accuracy (AUC: 0.5796-0.6774). CONCLUSION Taking into account specific bias, early values of CF (A5-A15) reliably predict maximum CF under all conditions and, therefore, allow for marked time savings in the interpretation of ROTEM® measurements. This may guide earlier and more specific treatment of CPB-related coagulation disorders.
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Affiliation(s)
- D. DIRKMANN
- Klinik für Anästhesiologie und Intensivmedizin; Universitätsklinikum Essen; Universität Duisburg-Essen; Essen; Germany
| | - K. GÖRLINGER
- Klinik für Anästhesiologie und Intensivmedizin; Universitätsklinikum Essen; Universität Duisburg-Essen; Essen; Germany
| | - F. DUSSE
- Klinik für Anästhesiologie und Intensivmedizin; Universitätsklinikum Essen; Universität Duisburg-Essen; Essen; Germany
| | - E. KOTTENBERG
- Klinik für Anästhesiologie und Intensivmedizin; Universitätsklinikum Essen; Universität Duisburg-Essen; Essen; Germany
| | - J. PETERS
- Klinik für Anästhesiologie und Intensivmedizin; Universitätsklinikum Essen; Universität Duisburg-Essen; Essen; Germany
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Ranucci M. Fibrinogen Supplementation in Cardiac Surgery: Where Are We Now and Where Are We Going? J Cardiothorac Vasc Anesth 2013. [DOI: 10.1053/j.jvca.2012.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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73
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Hemorrhage and Transfusions in the Surgical Patient. COMMON PROBLEMS IN ACUTE CARE SURGERY 2013. [PMCID: PMC7121296 DOI: 10.1007/978-1-4614-6123-4_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Hemorrhage is the leading cause of intraoperative deaths. Many cardiovascular and hepatobiliary procedures result in massive hemorrhage and postpartum hemorrhage events in labor and delivery place the patient at a high risk for mortality. Gastrointestinal bleeding from diverticulosis, varices, and ulcer disease can result in significant blood loss requiring massive transfusion and resuscitation from hemorrhagic shock. Timely and effective transfusion of blood products is of critical in these scenarios. The frequency in which blood component products are transfused in surgical patients begs for a greater understanding of them. The aim of this chapter is to provide clinicians with a discussion of the current literature on the various blood component products, their indications, and unique hemostatic conditions in the surgical patient. While the majority of data concerning optimal management of acquired coagulopathy and hemorrhagic shock resuscitation is based on trauma patients, many of the principles can and should be applied to the surgical patient (or likely any patient) with profound hemorrhage.
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Effect of haematocrit on fibrin-based clot firmness in the FIBTEM test. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 11:412-8. [PMID: 23245708 DOI: 10.2450/2012.0043-12] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 06/14/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Point-of-care thromboelastometry (ROTEM(®)) can be used to assess coagulation in whole blood. In the ROTEM(®) FIBTEM test, cytochalasin D eliminates the contribution of platelets to the whole blood clot; hence, only the remaining elements, including fibrinogen/fibrin, red blood cells and factor XIII, contribute to clot strength. We investigated the relationships between FIBTEM maximum clot firmness (MCF), whole blood fibrinogen concentration and plasma fibrinogen concentration to determine the impact of haematocrit on these parameters during cardiac surgery. MATERIALS AND METHODS The relationships between FIBTEM MCF and both whole blood fibrinogen concentration and plasma fibrinogen concentration (Clauss assay) were evaluated pre-operatively and after cardiopulmonary bypass/protamine administration in haematocrit-based subgroups. RESULTS The study included 157 patients. The correlation coefficient rho between FIBTEM MCF and plasma fibrinogen concentration was 0.68 at baseline and 0.70 after protamine, while that between FIBTEM MCF and whole blood fibrinogen concentration was 0.74 at baseline and 0.72 after protamine (all P <0.001). In subgroup analyses based on haematocrit levels, pre-operative FIBTEM MCF and whole blood fibrinogen concentration were both significantly higher (P <0.05) for the lowest haematocrit subgroup, but plasma fibrinogen concentration was similar in all groups. After protamine, no significant differences were observed between the lowest haematocrit group and the other groups for any of the three parameters. CONCLUSIONS The effect of haematocrit on blood clotting is not reflected by plasma fibrinogen concentration, in contrast to FIBTEM MCF which incorporates the contribution of haematocrit to whole blood clot firmness. This effect does, however, appear to be negligible in haemodiluted patients.
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Radulovic V, Baghaei F, Blixter IF, Samuelsson S, Jeppsson A. Comparable effect of recombinant and plasma-derived human fibrinogen concentrate on ex vivo clot formation after cardiac surgery. J Thromb Haemost 2012; 10:1696-8. [PMID: 22712790 DOI: 10.1111/j.1538-7836.2012.04823.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Bader SO, Ranier G. Is it necessary to maintain fibrinogen during hypothermia and major bleeding in vascular surgery? J Cardiothorac Vasc Anesth 2012; 26:e54-5; author reply e55-6. [PMID: 22763273 DOI: 10.1053/j.jvca.2012.03.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Indexed: 11/11/2022]
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Ogawa S, Szlam F, Bolliger D, Nishimura T, Chen EP, Tanaka KA. The Impact of Hematocrit on Fibrin Clot Formation Assessed by Rotational Thromboelastometry. Anesth Analg 2012; 115:16-21. [DOI: 10.1213/ane.0b013e31824d523b] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Amerikanou R, MacDonald S, Lawrence K, Large S, Besser MW. THE PAPWORTH PLUG - successful use of high dose fibrinogen concentrate and platelet concentrate in potential life-threatening complication after cardiopulmonary bypass surgery in a patient with Type 2M Vicenza von Willebrand Disease. Perfusion 2012; 27:307-10. [PMID: 22460926 DOI: 10.1177/0267659112443275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Anecdotally, fibrinogen concentrate (FC) has been used as a "universal" haemostatic agent in complex post-cardiopulmonary bypass (CPB) coagulopathy. We present a case where FC and two pools of platelets prevented life-threatening bleeding in a patient with moderate von Willebrand Disease (vWD) immediately post CPB.
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Affiliation(s)
- R Amerikanou
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, Cambs, UK
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Weiskopf RB. From Life-Blood Streaming to Hemostasis. Anesth Analg 2012; 114:247-9. [DOI: 10.1213/ane.0b013e31823cd50f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bolliger D, Seeberger MD, Tanaka KA. Principles and Practice of Thromboelastography in Clinical Coagulation Management and Transfusion Practice. Transfus Med Rev 2012; 26:1-13. [DOI: 10.1016/j.tmrv.2011.07.005] [Citation(s) in RCA: 288] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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