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Kelchtermans H, Pelkmans L, Bouwhuis A, Schurgers E, Lindhout T, Huskens D, Miszta A, Hemker HC, Lancé MD, de Laat B. Simultaneous measurement of thrombin generation and fibrin formation in whole blood under flow conditions. Thromb Haemost 2016; 116:134-45. [PMID: 27074907 DOI: 10.1160/th15-10-0801] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 03/28/2016] [Indexed: 11/05/2022]
Abstract
Assays based on the formation of thrombin and fibrin are frequently used, and results are considered exchangeable in research/clinical settings. However, thrombin generation and fibrin formation do not always go hand in hand and flow profoundly influences thrombus formation. We describe the technical/clinical evaluation of an assay to simultaneously measure thrombin generation and fibrin formation under conditions of flow. Introduction of a fluorometer into a 'cone and base principle'-based rheometer allowed the measurement of thrombin generation (using a thrombin-sensitive substrate) and fibrin formation (changes in viscosity), while applying a linear shear flow. Increasing shear rates inversely related with thrombin generation and fibrin formation. Increasing fibrinogen concentrations in defibrinated plasma resulted in increased thrombin generation and fibrin formation. In pre-operative samples of 70 patients undergoing cardiothoracic surgery, fibrin formation and thrombin generation parameters correlated with fibrinogen content, rotational thromboelastometry (ROTEM) and whole blood Calibrated Automated Thrombinography (CAT) parameters, respectively. Upon dividing patients into two groups based on the median clot strength, a significant difference in perioperative/total blood loss was established. In conclusion, we clinically evaluated a method capable of simultaneously measuring thrombin generation and fibrin formation in plasma/whole blood under continuous flow, rendering our method one step closer to physiology. Importantly, our test proved to be indicative for the amount of blood loss during/after cardiothoracic surgery.
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Affiliation(s)
- Hilde Kelchtermans
- Hilde Kelchtermans, Oxfordlaan 70, Maastricht 6229EV, The Netherlands, Tel.: +31 43 388 58 94, Fax: +31 43 388 45 70, E-mail:
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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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53
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Prakash S, Wiersema UF, Bihari S, Roxby D. Discordance between ROTEM® clotting time and conventional tests during unfractionated heparin–based anticoagulation in intensive care patients on extracorporeal membrane oxygenation. Anaesth Intensive Care 2016; 44:85-92. [DOI: 10.1177/0310057x1604400113] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We hypothesised that ROTEM® (Basel, Switzerland) INTEM® (ROTEM, Basel, Switzerland) clotting time (CT) would have good agreement with activated partial thromboplastin time (aPTT) in determining whether a dose adjustment should be made to the unfractionated heparin (UFH) infusion in patients on extracorporeal membrane oxygenation. All patients treated with extracorporeal membrane oxygenation over a five-year period were included for data analysis. Retrospective analysis was performed of prospectively collected data points, wherein aPTT, activated CT and ROTEM was performed simultaneously to monitor UFH–based anticoagulation. Two hundred data points were available for analysis. Turnaround time was shortest for activated CT followed by ROTEM and aPTT. Despite achieving therapeutic aPTT targets, the majority (>50%) of INTEM CT results were within normal limits. The aPTT and INTEM CT results correlated weakly (r=0.31, 95% confidence interval [0.17, 0.43]) and there was no agreement between the directional changes of aPTT and INTEM CT results on successive days (χ2 = 2.33, P=0.17). Due to relative insensitivity, INTEM CT–guided UFH titration was estimated to result in a 289% increase in incidence of up-titration, over aPTT–guided titration. The INTEM CT results (r=0.36, 95% confidence interval [0.23, 0.48]) correlated weakly with UFH infusion rates. The UFH infusion rate only explained 13% variability in INTEM CT values. While haemorrhagic complications were frequent, no major clotting complications were encountered. Our results demonstrated that aPTT and INTEM CT do not provide equivalent information to guide UFH infusion rate titration during extracorporeal membrane oxygenation. Our study suggests caution regarding the use of ROTEM for guiding UFH–based anticoagulation as it may lead to excessive UFH exposure.
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Affiliation(s)
- S. Prakash
- Department of Intensive Care, Flinders Medical Centre, Bedford Park, South Australia
| | - U. F. Wiersema
- Department of Intensive Care, Flinders Medical Centre, Bedford Park, South Australia
| | - S. Bihari
- Department of Intensive Care, Flinders Medical Centre, Bedford Park, South Australia
| | - D. Roxby
- SA Pathology Transfusion Medicine, Flinders Medical Centre, Bedford Park, South Australia
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Mace H, Lightfoot N, McCluskey S, Selby R, Roy D, Timoumi T, Karkouti K. Validity of Thromboelastometry for Rapid Assessment of Fibrinogen Levels in Heparinized Samples During Cardiac Surgery: A Retrospective, Single-center, Observational Study. J Cardiothorac Vasc Anesth 2016; 30:90-5. [DOI: 10.1053/j.jvca.2015.04.030] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Indexed: 11/11/2022]
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56
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Llau JV, Acosta FJ, Escolar G, Fernández-Mondéjar E, Guasch E, Marco P, Paniagua P, Páramo JA, Quintana M, Torrabadella P. [Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)]. ACTA ACUST UNITED AC 2015; 63:e1-e22. [PMID: 26688462 DOI: 10.1016/j.redar.2015.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/17/2015] [Indexed: 12/23/2022]
Abstract
Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).
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Affiliation(s)
- J V Llau
- Anestesia y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, España
| | - F J Acosta
- Anestesia y Reanimación, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - G Escolar
- Hemoterapia y Hematología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - E Fernández-Mondéjar
- Servicio de Cuidados Críticos y Urgencias, Hospital Universitario Virgen de las Nieves; Instituto de Investigación Biosanitaria ibs.Granada, Granada, España.
| | - E Guasch
- Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - P Marco
- Hemoterapia y Hematología, Hospital General de Alicante, Alicante, España
| | - P Paniagua
- Anestesia y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J A Páramo
- Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España
| | - M Quintana
- Medicina Intensiva, Hospital Universitario La Paz, Madrid, España
| | - P Torrabadella
- Unidad de Cuidados Intensivos, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
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Llau JV, Acosta FJ, Escolar G, Fernández-Mondéjar E, Guasch E, Marco P, Paniagua P, Páramo JA, Quintana M, Torrabadella P. Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document). Med Intensiva 2015; 39:483-504. [PMID: 26233588 DOI: 10.1016/j.medin.2015.05.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 05/14/2015] [Accepted: 05/17/2015] [Indexed: 12/30/2022]
Abstract
Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).
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Affiliation(s)
- J V Llau
- Anestesia y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, España
| | - F J Acosta
- Anestesia y Reanimación, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, España
| | - G Escolar
- Hemoterapia y Hematología, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - E Fernández-Mondéjar
- Servicio de Cuidados Críticos y Urgencias, Hospital Universitario Virgen de las Nieves; Instituto de Investigación Biosanitaria ibs.Granada, Granada, España.
| | - E Guasch
- Anestesia y Reanimación, Hospital Universitario La Paz, Madrid, España
| | - P Marco
- Hemoterapia y Hematología, Hospital General de Alicante, Alicante, España
| | - P Paniagua
- Anestesia y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J A Páramo
- Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España
| | - M Quintana
- Medicina Intensiva, Hospital Universitario La Paz, Madrid, España
| | - P Torrabadella
- Unidad de Cuidados Intensivos, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
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Solomon C, Schöchl H, Ranucci M, Schlimp CJ. Can the Viscoelastic Parameter α-Angle Distinguish Fibrinogen from Platelet Deficiency and Guide Fibrinogen Supplementation? Anesth Analg 2015. [PMID: 26197367 DOI: 10.1213/ane.0000000000000738] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Viscoelastic tests such as thrombelastography (TEG, Haemoscope Inc., Niles, IL) and thromboelastometry (ROTEM, Tem International GmbH, Munich, Germany), performed in whole blood, are increasingly used at the point-of-care to characterize coagulopathic states and guide hemostatic therapy. An algorithm, based on a mono-analysis (kaolin-activated assay) approach, was proposed in the TEG patent (issued in 2004) where the α-angle and the maximum amplitude parameters are used to guide fibrinogen supplementation and platelet administration, respectively. Although multiple assays for both the TEG and ROTEM devices are now available, algorithms based on TEG mono-analysis are still used in many institutions. In light of more recent findings, we discuss here the limitations and inaccuracies of the mono-analysis approach. Research shows that both α-angle and maximum amplitude parameters reflect the combined contribution of fibrinogen and platelets to clot strength. Therefore, although TEG mono-analysis is useful for identifying a coagulopathic state, it cannot be used to discriminate between fibrin/fibrinogen and/or platelet deficits, respectively. Conversely, the use of viscoelastic methods where 2 assays can be run simultaneously, one with platelet inhibitors and one without, can effectively allow for the identification of specific coagulopathic states, such as insufficient fibrin formation or an insufficient contribution of platelets to clot strength. Such information is critical for making the appropriate choice of hemostatic therapy.
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Affiliation(s)
- Cristina Solomon
- From the *CSL Behring, Marburg, Germany; †Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; ‡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 ∥Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Klagenfurt, Klagenfurt, Austria
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59
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Erber M, Lee G. The influence of excipients commonly used in freeze drying on whole blood coagulation dynamics assessed by rotational thromboelastometry. Clin Chem Lab Med 2015; 53:1605-11. [PMID: 25719321 DOI: 10.1515/cclm-2014-1046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 01/05/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Lyophilized reagents are used on a daily basis in coagulation diagnostics. They often contain a number of excipients in addition to the active compound. Some of these excipients may, however, influence coagulation dynamics. METHODS Besides from plasmatic coagulation bulking agents may influence platelet properties. We therefore studied the influence of a variety of bulking agents (glycine, mannitol, sucrose and trehalose) as well as a surfactant (Tween® 80) on whole blood coagulation using thromboelastometry (ROTEM®) and platelet function analysis (ROTEM® platelet). RESULTS Both disaccharides as well as Tween® 80 did not influence whole blood coagulation in the concentration range investigated. The addition of glycine and mannitol solutions to the ROTEM® measurement leads to an impaired clot formation as well as overall clot strength while clotting initiation remained barely influenced. Hypertonic glycine and mannitol solutions exhibit different clot formation impairment when correlated to their osmolar concentration and compared to equally osmolar NaCl-solutions. The effect of glycine was assigned to fibrin formation impairment identified with the FIBTEM assay. Platelet function analysis revealed that hypertonic glycine solutions do not alter platelet function but hypertonic mannitol and NaCl solutions do. CONCLUSIONS While the influence observed for glycine may be due to fibrinogen precipitation, the mechanism of mannitol appears to be more complex as platelet function as well as fibrin-based clot formation are influenced. This study therefore demonstrates the necessity to check for coagulation impairment due to compounds contained in lyophilized reagents.
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Naik BI, Pajewski TN, Bogdonoff DI, Zuo Z, Clark P, Terkawi AS, Durieux ME, Shaffrey CI, Nemergut EC. Rotational thromboelastometry–guided blood product management in major spine surgery. J Neurosurg Spine 2015; 23:239-49. [DOI: 10.3171/2014.12.spine14620] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Major spinal surgery in adult patients is often associated with significant intraoperative blood loss. Rotational thromboelastometry (ROTEM) is a functional viscoelastometric method for real-time hemostasis testing. In this study, the authors sought to characterize the coagulation abnormalities encountered in spine surgery and determine whether a ROTEM-guided, protocol-based approach to transfusion reduced blood loss and blood product use and cost.
METHODS
A hospital database was used to identify patients who had undergone adult deformity correction spine surgery with ROTEM-guided therapy. All patients who received ROTEM-guided therapy (ROTEM group) were matched with historical cohorts whose coagulation status had not been evaluated with ROTEM but who were treated using a conventional clinical and point-of-care laboratory approach to transfusion (Conventional group). Both groups were subdivided into 2 groups based on whether they had received intraoperative tranexamic acid (TXA), the only coagulation-modifying medication administered intraoperatively during the study period. In the ROTEM group, 26 patients received TXA (ROTEM-TXA group) and 24 did not (ROTEM-nonTXA group). Demographic, surgical, laboratory, and perioperative transfusion data were recorded. Data were analyzed by rank permutation test, adapted for the 1:2 ROTEM-to-Conventional matching structure, with p < 0.05 considered significant.
RESULTS
Comparison of the 2 groups in which TXA was used showed significantly less fresh-frozen plasma (FFP) use in the ROTEM-TXA group than in the Conventional-TXA group (median 0 units [range 0–4 units] vs 2.5 units [range 0–13 units], p < 0.0002) but significantly more cryoprecipitate use (median 1 unit [range 0–4 units] in the ROTEM-TXA group vs 0 units [range 0–2 units] in the Conventional-TXA group, p < 0.05), with a nonsignificant reduction in blood loss (median 2.6 L [range 0.9–5.4 L] in the ROTEM-TXA group vs 2.9 L [0.7–7.0 L] in the Conventional-TXA group, p = 0.21). In the 2 groups in which TXA was not used, the ROTEM-nonTXA group showed significantly less blood loss than the Conventional-nonTXA group (median 1 L [range 0.2–6.0 L] vs 1.5 L [range 1.0–4.5 L], p = 0.0005), with a trend toward less transfusion of packed red blood cells (pRBC) (median 0 units [range 0–4 units] vs 1 unit [range 0–9 units], p = 0.09]. Cryoprecipitate use was increased and FFP use decreased in response to ROTEM analysis identifying hypofibrinogenemia as a major contributor to ongoing coagulopathy.
CONCLUSIONS
In major spine surgery, ROTEM-guided transfusion allows for standardization of transfusion practices and early identification and treatment of hypofibrinogenemia. Hypofibrinogenemia is an important cause of the coagulopathy encountered during these procedures and aggressive management of this complication is associated with less intraoperative blood loss, reduced transfusion requirements, and decreased transfusion-related cost.
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Affiliation(s)
| | | | | | - Zhiyi Zuo
- Departments of 1Anesthesiology,
- 2Neurosurgery, and
| | - Pamela Clark
- 3Pathology, University of Virginia, Charlottesville, Virginia
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61
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Erber M, Lee G. Cryopellets based on amorphous organic calcium salts: Production, characterization and their usage in coagulation diagnostics. POWDER TECHNOL 2015. [DOI: 10.1016/j.powtec.2015.04.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Radulovic V, Laffin A, Hansson KM, Backlund E, Baghaei F, Jeppsson A. Heparin and Protamine Titration Does Not Improve Haemostasis after Cardiac Surgery: A Prospective Randomized Study. PLoS One 2015; 10:e0130271. [PMID: 26134993 PMCID: PMC4489911 DOI: 10.1371/journal.pone.0130271] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 05/18/2015] [Indexed: 11/18/2022] Open
Abstract
Background Bleeding complications are common in cardiac surgery. Perioperative handling of heparin and protamine may influence the haemostasis. We hypothesized that heparin and protamine dosing based on individual titration curves would improve haemostasis in comparison to standard dosing. Subjects and Methods Sixty patients scheduled for first time elective coronary artery bypass grafting or valve surgery were included in a prospective randomized study. The patients were randomized to heparin and protamine dosing with Hepcon HMS Plus device or to standard weight and activated clotting time (ACT) based dosing. Blood samples were collected before and 10 minutes, 2 hours and 4 hours after cardiopulmonary bypass. Primary endpoint was endogenous thrombin potential in plasma 2 hours after surgery as assessed by calibrated automated thrombography. Secondary endpoints included total heparin and protamine doses, whole blood clot formation (thromboelastometry) and post-operative bleeding volume and transfusions. Heparin effect was assessed by measuring anti-Xa activity. Results Endogenous thrombin potential and clot formation deteriorated in both groups after surgery without statistically significant intergroup difference. There were no significant differences between the groups in total heparin and protamine doses, heparin effect, or postoperative bleeding and transfusions at any time point. Significant inverse correlations between anti-Xa activity and endogenous thrombin potential were observed 10 min (r = -0.43, p = 0.001), 2 hours (r = -0.66, p<0.001) and 4 hours after surgery (r = -0.58, p<0.001). Conclusion In conclusion, the results suggest that perioperative heparin and protamine dosing based on individual titration curves does not improve haemostasis after cardiac surgery. Postoperative thrombin generation capacity correlates to residual heparin effect. Trial Registration www.isrctn.comISRCTN14201041.
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Affiliation(s)
- Vladimir Radulovic
- Department of Medicine/Hematology and Coagulation Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Laffin
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Erika Backlund
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fariba Baghaei
- Department of Medicine/Hematology and Coagulation Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
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63
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Ji SM, Kim SH, Nam JS, Yun HJ, Choi JH, Lee EH, Choi IC. Predictive value of rotational thromboelastometry during cardiopulmonary bypass for thrombocytopenia and hypofibrinogenemia after weaning of cardiopulmonary bypass. Korean J Anesthesiol 2015; 68:241-8. [PMID: 26045926 PMCID: PMC4452667 DOI: 10.4097/kjae.2015.68.3.241] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 01/02/2015] [Accepted: 01/03/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The early detection of coagulopathy helps guide decisions regarding optimal transfusion management during cardiac surgery. This study aimed to determine whether rotational thromboelastometry (ROTEM) analysis during cardiopulmonary bypass (CPB) could predict thrombocytopenia and hypofibrinogenemia after CPB. METHODS We analyzed 138 cardiac surgical patients for whom ROTEM tests and conventional laboratory tests were performed simultaneously both during and after CPB. An extrinsically activated ROTEM test (EXTEM), a fibrin-specific ROTEM test (FIBTEM) and PLTEM calculated by subtracting FIBTEM from EXTEM were evaluated. Correlations between clot amplitude at 10 min (A10), maximal clot firmness, platelet count, and fibrinogen concentrations at each time point were calculated. A receiver operating characteristic analysis with area under the curve (AUC) was used to assess the thresholds of EXTEM, PLTEM and FIBTEM parameters during CPB and for predicting thrombocytopenia and hypofibrinogenemia after weaning of CPB. RESULTS The A10 on EXTEM, PLTEM, and FIBTEM during CPB showed a good correlation with platelet counts (r = 0.622 on EXTEM and r = 0.637 on PLTEM; P < 0.0001 for each value) and fibrinogen levels (r = 0.780; P < 0.0001) after CPB. A10 on a FIBTEM threshold of 8 mm during the CPB predicted a fibrinogen concentration < 150 mg/dl (AUC = 0.853) after CPB. Additionally, the threshold level of A10 on EXTEM during CPB for predicting platelet counts < 100,000 /µl after CPB was 42 mm (AUC = 0.768). CONCLUSIONS EXTEM, PLTEM, and FIBTEM parameters during CPB may be useful for predicting thrombocytopenia and hypofibrinogenemia after weaning of CPB.
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Affiliation(s)
- Sung-Mi Ji
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Sik Nam
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Joo Yun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Hyun Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Erdoes G, Gerster G, Colucci G, Kaiser H, Alberio L, Eberle B. Prediction of Post-Weaning Fibrinogen Status during Cardiopulmonary Bypass: An Observational Study in 110 Patients. PLoS One 2015; 10:e0126692. [PMID: 26011420 PMCID: PMC4444179 DOI: 10.1371/journal.pone.0126692] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/13/2015] [Indexed: 12/13/2022] Open
Abstract
Background After cardiac surgery with cardiopulmonary bypass (CPB), acquired coagulopathy often leads to post-CPB bleeding. Though multifactorial in origin, this coagulopathy is often aggravated by deficient fibrinogen levels. Objective To assess whether laboratory and thrombelastometric testing on CPB can predict plasma fibrinogen immediately after CPB weaning. Patients / Methods This prospective study in 110 patients undergoing major cardiovascular surgery at risk of post-CPB bleeding compares fibrinogen level (Clauss method) and function (fibrin-specific thrombelastometry) in order to study the predictability of their course early after termination of CPB. Linear regression analysis and receiver operating characteristics were used to determine correlations and predictive accuracy. Results Quantitative estimation of post-CPB Clauss fibrinogen from on-CPB fibrinogen was feasible with small bias (+0.19 g/l), but with poor precision and a percentage of error >30%. A clinically useful alternative approach was developed by using on-CPB A10 to predict a Clauss fibrinogen range of interest instead of a discrete level. An on-CPB A10 ≤10 mm identified patients with a post-CPB Clauss fibrinogen of ≤1.5 g/l with a sensitivity of 0.99 and a positive predictive value of 0.60; it also identified those without a post-CPB Clauss fibrinogen <2.0 g/l with a specificity of 0.83. Conclusions When measured on CPB prior to weaning, a FIBTEM A10 ≤10 mm is an early alert for post-CPB fibrinogen levels below or within the substitution range (1.5–2.0 g/l) recommended in case of post-CPB coagulopathic bleeding. This helps to minimize the delay to data-based hemostatic management after weaning from CPB.
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Affiliation(s)
- Gabor Erdoes
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
- * E-mail:
| | - Germaine Gerster
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
| | | | - Heiko Kaiser
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
| | - Lorenzo Alberio
- Hématologie non-maligne et Hémostase, Service et Laboratoire central d`Hématologie, University Hospital Lausanne, Lausanne, Switzerland
| | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
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Corredor C, Wasowicz M, Karkouti K, Sharma V. The role of point-of-care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta-analysis. Anaesthesia 2015; 70:715-31. [PMID: 25916344 DOI: 10.1111/anae.13083] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 12/23/2022]
Abstract
This systematic review and meta-analysis appraises the utility of point-of-care platelet function tests for predicting blood loss and transfusion requirements in cardiac surgical patients, and analyses whether their use within a transfusion management algorithm is associated with improved patient outcomes. We included 30 observational studies incorporating 3044 patients in the qualitative assessment, and nine randomised controlled trials including 1057 patients in the meta-analysis. Platelet function tests demonstrated significant variability in their ability to predict blood loss and transfusion requirements. Their use within a blood transfusion algorithm demonstrated a reduction in blood loss at longest follow-up (mean difference -102.9 ml (95% CI -149.9 to -56.1 ml), p < 0.001), and transfusion of packed red cells (RR 0.86 (95% CI 0.78-0.94), p = 0.001) and fresh frozen plasma (RR 0.42 (95% CI 0.30-0.59), p < 0.001). Viscoelastic methods used in combination with other platelet function tests achieved greater reduction in blood loss (mean difference -111.8 ml (95% CI -174.9 to -49.1 ml), p = 0.0005) compared with their use alone (mean difference -90.6 ml (95% CI 166.1-15.0 ml), p = 0.02). We conclude that incorporation of point-of-care platelet function tests into transfusion management algorithms is associated with a reduction in blood loss and transfusion requirements in cardiac surgery patients.
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Affiliation(s)
- C Corredor
- Department of Anaesthesia, St. George's Hospital, London, UK
| | - M Wasowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - V Sharma
- Department of Anaesthesia, St. George's Hospital, London, UK
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Fayed N, Mourad W, Yassen K, Görlinger K. Preoperative Thromboelastometry as a Predictor of Transfusion Requirements during Adult Living Donor Liver Transplantation. Transfus Med Hemother 2015; 42:99-108. [PMID: 26019705 DOI: 10.1159/000381733] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 03/20/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The ability to predict transfusion requirements may improve perioperative bleeding management as an integral part of a patient blood management program. Therefore, the aim of our study was to evaluate preoperative thromboelastometry as a predictor of transfusion requirements for adult living donor liver transplant recipients. METHODS The correlation between preoperative thromboelastometry variables in 100 adult living donor liver transplant recipients and intraoperative blood transfusion requirements was examined by univariate and multivariate linear regression analysis. Thresholds of thromboelastometric parameters for prediction of packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, and cryoprecipitate transfusion requirements were determined with receiver operating characteristics analysis. The attending anesthetists were blinded to the preoperative thromboelastometric analysis. However, a thromboelastometry-guided transfusion algorithm with predefined trigger values was used intraoperatively. The transfusion triggers in this algorithm did not change during the study period. RESULTS Univariate analysis confirmed significant correlations between PRBCs, FFP, platelets or cryoprecipitate transfusion requirements and most thromboelastometric variables. Backward stepwise logistic regression indicated that EXTEM coagulation time (CT), maximum clot firmness (MCF) and INTEM CT, clot formation time (CFT) and MCF are independent predictors for PRBC transfusion. EXTEM CT, CFT and FIBTEM MCF are independent predictors for FFP transfusion. Only EXTEM and INTEM MCF were independent predictors of platelet transfusion. EXTEM CFT and MCF, INTEM CT, CFT and MCF as well as FIBTEM MCF are independent predictors for cryoprecipitate transfusion. Thromboelastometry-based regression equation accounted for 63% of PRBC, 83% of FFP, 61% of cryoprecipitate, and 44% of platelet transfusion requirements. CONCLUSION Preoperative thromboelastometric analysis is helpful to predict transfusion requirements in adult living donor liver transplant recipients. This may allow for better preparation and less cross-matching prior to surgery. The findings of our study need to be re-validated in a second prospective patient population.
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Affiliation(s)
- Nirmeen Fayed
- Department of Anesthesia, National Liver Institute, Menoufiya University, Shebeen El Kom City, Egypt
| | - Wessam Mourad
- Department of Public Health, Community Medicine and Statistics, National Liver Institute, Menoufiya University, Shebeen El Kom City, Egypt
| | - Khaled Yassen
- Department of Anesthesia, National Liver Institute, Menoufiya University, Shebeen El Kom City, Egypt
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany ; Tem International GmbH, Munich, Germany
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Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*. Anesthesiology 2015; 122:241-75. [PMID: 25545654 DOI: 10.1097/aln.0000000000000463] [Citation(s) in RCA: 448] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abstract
The American Society of Anesthesiologists Committee on Standards and Practice Parameters and the Task Force on Perioperative Blood Management presents an updated report of the Practice Guidelines for Perioperative Blood Management.
Supplemental Digital Content is available in the text.
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Ogawa S, Tanaka KA, Nakajima Y, Nakayama Y, Takeshita J, Arai M, Mizobe T. Fibrinogen measurements in plasma and whole blood: a performance evaluation study of the dry-hematology system. Anesth Analg 2015; 120:18-25. [PMID: 25225891 DOI: 10.1213/ane.0000000000000448] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND An accurate and rapid determination of fibrinogen level is important during hemorrhage to establish a timely hemostatic intervention. The accuracy of fibrinogen measurements may be affected by the specific methodology for its determination, fluid therapies, and anticoagulant agents. The dry-hematology method (DRIHEMATO®) is a novel approach to determine fibrinogen levels in plasma and whole blood based on thrombin-activated coagulation time. We hypothesized that plasma or whole blood fibrinogen level using the dry-hematology method would be similar to those measured with conventional plasma fibrinogen assays. METHODS Acquired hypofibrinogenemia was modeled by serial dilutions of blood samples obtained from 12 healthy volunteers. Citrated whole blood samples were diluted with either normal saline, 5% human albumin, or 6% hydroxyethyl starch to achieve 25%, 50%, and 75% volume replacement. The dry-hematology method, the Clauss method, the prothrombin time (PT)-derived method, determination of antigen levels, and thromboelastometric fibrin formation were compared in plasma or whole blood samples. The effect of heparin on each assay was examined (0 to 6 IU/mL). Comparisons of dry-hematology and other methods were also conducted using ex vivo samples obtained from cardiac surgical patients (n = 60). RESULTS In plasma samples, there were no significant differences between dry-hematology and the Clauss method, while dry-hematology showed lower fibrinogen levels compared with PT-derived and antigen level methods. The dry-hematology method yielded acceptable concordance correlation coefficients (Pc) with the Clauss method, the PT-derived method, and fibrinogen antigen levels (Pc = 0.91-0.99). The type of diluents and heparin affected the results of the PT-derived method and thromboelastometric assay, but not the dry-hematology method. In cardiac surgical patients, the overall correlation in fibrinogen levels between dry-hematology and the other methods was comparable to the results from in vitro dilution experiments. The dry-hematology reported higher fibrinogen values in whole blood compared with those measured in plasma samples, but hematocrit adjustment decreased the bias between whole blood and plasma samples from 73 mg/dL (95% prediction interval: 40, 106) to -13 mg/dL (95% prediction interval: -35, 8.5). CONCLUSIONS This study demonstrated that fibrinogen levels can be accurately assessed by the dry-hematology method in plasma and the results are not affected by heparin or colloids. For whole blood fibrinogen measurements by dry-hematology, hematocrit adjustment is necessary to compensate for dynamic changes in hematocrit in perioperative bleeding settings.
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Affiliation(s)
- Satoru Ogawa
- From the Department of Anesthesiology and Intensive Care, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania; and Research Institute, A&T Corporation, Kanagawa, Japan
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Pathirana S, Wong G, Williams P, Yang K, Kershaw G, Dunkley S, Kam PCA. The Effects of Haemodilution with Albumin on Coagulation in Vitro as Assessed by Rotational Thromboelastometry. Anaesth Intensive Care 2015; 43:187-92. [DOI: 10.1177/0310057x1504300207] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We investigated the in vitro viscoelastic changes of progressive haemodilution with 4% albumin compared with normal saline (NS) using rotational thromboelastometry (ROTEM®, Pentapharm Co., Munich, Germany). Whole blood samples obtained from 20 healthy volunteers were diluted in vitro with 4% albumin or NS by 10%, 20% and 40%. Fibrinogen concentration and ROTEM® (EXTEM [screening test for the extrinsic haemostasis system], FIBTEM [EXTEM-based assay for the fibrin part of the clot]) variables including coagulation time, clot formation time (CFT), α-angle, maximum clot firmness and lysis index were measured in the undiluted sample and at each degree of haemodilution. There was no significant difference in fibrinogen concentration at equivalent haemodilutions with normal saline and 4% albumin solutions. Forty percent haemodilution with albumin significantly prolonged coagulation time (EXTEM P=0.007, FIBTEM P=0.0001) and significantly decreased lysis index (FIBTEM P=0.009) compared with NS. A significant decrease in maximum clot firmness from undiluted measurements ( P=0.05) was observed at lower haemodilutions with albumin (20% with EXTEM, 10% with FIBTEM) compared with NS (40% with EXTEM and FIBTEM). The adverse effects of large degrees of haemodilution with 4% albumin solution are in excess of what can be explained by haemodilution alone. This study suggests that large degrees of haemodilution with albumin impair fibrinogen activity to a greater extent than equivalent degrees of haemodilution with NS.
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Affiliation(s)
- S. Pathirana
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G. Wong
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P. Williams
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - K. Yang
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G. Kershaw
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - S. Dunkley
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P. C. A. Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
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Chapin JC, Hajjar KA. Fibrinolysis and the control of blood coagulation. Blood Rev 2015; 29:17-24. [PMID: 25294122 PMCID: PMC4314363 DOI: 10.1016/j.blre.2014.09.003] [Citation(s) in RCA: 440] [Impact Index Per Article: 48.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 09/02/2014] [Indexed: 12/11/2022]
Abstract
Fibrin plays an essential role in hemostasis as both the primary product of the coagulation cascade and the ultimate substrate for fibrinolysis. Fibrinolysis efficiency is greatly influenced by clot structure, fibrinogen isoforms and polymorphisms, the rate of thrombin generation, the reactivity of thrombus-associated cells such as platelets, and the overall biochemical environment. Regulation of the fibrinolytic system, like that of the coagulation cascade, is accomplished by a wide array of cofactors, receptors, and inhibitors. Fibrinolytic activity can be generated either on the surface of a fibrin-containing thrombus, or on cells that express profibrinolytic receptors. In a widening spectrum of clinical disorders, acquired and congenital defects in fibrinolysis contribute to disease morbidity, and new assays of global fibrinolysis now have potential predictive value in multiple clinical settings. Here, we summarize the basic elements of the fibrinolytic system, points of interaction with the coagulation pathway, and some recent clinical advances.
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Affiliation(s)
- John C Chapin
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medical College, 520 East 70th Street, New York, NY 10065, USA.
| | - Katherine A Hajjar
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medical College, 520 East 70th Street, New York, NY 10065, USA; Division of Hematology-Oncology, Department of Pediatrics, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA; Department of Cell and Developmental Biology, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA.
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71
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Nakayama Y, Nakajima Y, Tanaka K, Sessler D, Maeda S, Iida J, Ogawa S, Mizobe T. Thromboelastometry-guided intraoperative haemostatic management reduces bleeding and red cell transfusion after paediatric cardiac surgery. Br J Anaesth 2015; 114:91-102. [DOI: 10.1093/bja/aeu339] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Mallaiah S, Barclay P, Harrod I, Chevannes C, Bhalla A. Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage. Anaesthesia 2014; 70:166-75. [PMID: 25289791 DOI: 10.1111/anae.12859] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2014] [Indexed: 12/23/2022]
Abstract
We compared blood component requirements during major obstetric haemorrhage, following the introduction of fibrinogen concentrate. A prospective study of transfusion requirements and patient outcomes was performed for 12 months to evaluate the major obstetric haemorrhage pathway using shock packs (Shock Pack phase). The study was repeated after the pathway was amended to include fibrinogen concentrate (Fibrinogen phase). The median (IQR [range]) number of blood components given was 8.0 (3.0-14.5 [0-32]) during the Shock Pack phase, and 3.0 (2.0-5.0 [0-26]) during the Fibrinogen phase (p = 0.0004). The median (IQR [range]) quantity of fibrinogen administered was significantly greater in the Shock Pack phase, 3.2 (0-7.1 [0-20.4]) g, than in the Fibrinogen phase, 0 (0-3.0 [0-12.4]) g, p = 0.0005. Four (9.5%) of 42 patients in the Shock Pack phase developed transfusion associated circulatory overload compared with none of 51 patients in the Fibrinogen phase (p = 0.038). Fibrinogen concentrate allows prompt correction of coagulation deficits associated with major obstetric haemorrhage, reducing the requirement for blood component therapy and the attendant risks of complications.
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Affiliation(s)
- S Mallaiah
- Liverpool Women's Hospital, Liverpool, UK
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Comparison of three point-of-care testing devices to detect hemostatic changes in adult elective cardiac surgery: a prospective observational study. BMC Anesthesiol 2014; 14:80. [PMID: 25276093 PMCID: PMC4179787 DOI: 10.1186/1471-2253-14-80] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 07/21/2014] [Indexed: 11/19/2022] Open
Abstract
Background Bleeding complications in cardiac surgery may lead to increased morbidity and mortality. Traditional blood coagulation tests are not always suitable to detect rapid changes in the patient's coagulation status. Point-of-care instruments such as the TEG (thromboelastograph) and RoTEM (thromboelastometer) have been shown to be useful as a guide for the clinician in the choice of blood products and they may lead to a reduction in the need for blood transfusion, contributing to better patient blood management. Methods The purpose of this study was to evaluate the ability of the TEG, RoTEM and Sonoclot instruments to detect changes in hemostasis in elective cardiac surgery with cardiopulmonary bypass and to investigate possible correlations between variables from these three instruments and routine hematological coagulation tests. Blood samples from thirty-five adult patients were drawn before and after surgery and analyzed in TEG, RoTEM, Sonoclot and routine coagulation tests. Data were compared using repeated measures analysis of variance and Pearson's test for linear correlation. Results We found significant changes for all TEG variables after surgery, for three of the RoTEM variables, and for one variable from the Sonoclot. There were significant correlations postoperatively between plasma fibrinogen levels and variables from the three instruments. Conclusions TEG and RoTEM may be used to detect changes in hemostasis following cardiac surgery with CPB. Sonoclot seems to be less suitable to detect such changes. Variables from the three instruments correlated with plasma fibrinogen and could be used to monitor treatment with fibrinogen concentrate.
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Abstract
PURPOSE OF REVIEW The recent advances in hemostatic monitoring, and discussion of the clinical implications of hemostatic therapies based on different blood components and factor concentrates. RECENT FINDINGS Implementing suitable laboratory tests and transfusion protocols is highly recommended because the laboratory test guided, protocol-driven transfusion approach reduces blood component utilization, and possibly leads to improved outcomes. Timely assessment of coagulation has been difficult using conventional coagulation tests, but thrombocytopenia, fibrin polymerization defects, and fibrinolysis can be quickly assessed on thromboelastometry. The latter testing can be applied to guide the dosing of fibrinogen and prothrombin complex concentrate, which are selectively used to correct fibrinogen deficiency, and improve thrombin generation in acquired coagulopathy. These therapeutic approaches are novel, and potentially effective in reducing the exposure to allogeneic components (e.g., plasma and platelets) and side-effects of transfusion. Although the accessibility of different therapies among different countries, tranexamic acid is widely available, and is an effective blood conservation measure with a good safety profile in various surgical settings. SUMMARY Our understanding of perioperative coagulopathy, diagnostic tools, and therapeutic approaches has evolved in recent years. Additional multidisciplinary efforts are required to understand the optimal combinations, cost-effectiveness, and safety profiles of allogeneic components, and available factor concentrates.
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Franchi F, Hammad JS, Rollini F, Tello-Montoliu A, Patel R, Darlington A, Kraemer DF, Cho JR, DeGroat C, Bhatti M, Taha M, Angiolillo DJ. Role of thromboelastography and rapid thromboelastography to assess the pharmacodynamic effects of vitamin K antagonists. J Thromb Thrombolysis 2014; 40:118-25. [DOI: 10.1007/s11239-014-1130-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ormonde L. Plasma fibrinogen measurement during cardiopulmonary bypass: a tool for early guidance of fibrinogen supplementation in cardiovascular surgery? Br J Anaesth 2014; 112:1120-1. [PMID: 24829426 DOI: 10.1093/bja/aeu172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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van Ryn J, Grottke O, Spronk H. Measurement of dabigatran in standardly used clinical assays, whole blood viscoelastic coagulation, and thrombin generation assays. Clin Lab Med 2014; 34:479-501. [PMID: 25168938 DOI: 10.1016/j.cll.2014.06.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Dabigatran, a direct thrombin inhibitor, is increasingly used clinically as one of the new oral anticoagulants. This review summarizes the assays available to measure its activity and includes the relative sensitivity of the different assays for this agent. In addition to plasma-based clotting tests, assays commonly used in surgical/emergency settings, such as activated clotting time and thromboelastometry/thromboelastography, are reviewed. In addition, the thrombin generation assay is discussed as an important method to determine the potential risk of thrombosis or bleeding and its relevance to the measurement of direct thrombin inhibitors.
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Affiliation(s)
- Joanne van Ryn
- Department of CardioMetabolic Disease Research, Boehringer Ingelheim Pharma GmbH & Co KG, Birkendorfer Street 65, Biberach 88397, Germany.
| | - Oliver Grottke
- Department of Anesthesiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, Aachen 52074, Germany
| | - Henri Spronk
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, PO Box 616, Maastricht 6200 MD, The Netherlands
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Foley SR, Solano C, Simonova G, Spanevello MM, Bird RJ, Semple JW, Jackson DE, Schibler A, Fraser JF, Fung YL. A comprehensive study of ovine haemostasis to assess suitability to model human coagulation. Thromb Res 2014; 134:468-73. [PMID: 24929837 DOI: 10.1016/j.thromres.2014.05.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 05/17/2014] [Accepted: 05/17/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Similarities in size, anatomy and physiology have supported the use of sheep to model a wide range of human diseases, including coagulopathy. However, coagulation studies involving sheep are limited by the absence of high quality data defining normal ovine coagulation and fibrinolysis. MATERIALS AND METHODS Full blood examination, routine and specialised coagulation tests, rotational thromboelastometry and whole blood platelet aggregometry was performed on 50 healthy Samm & Border Leicester Cross ewes and compared to corresponding human ranges. Intraspecies breed and gender variability was investigated by comparison to a smaller population of 13 healthy Merino wethers. RESULTS Ovine coagulation was similar to human according to routine coagulation methods (PT, aPTT, TCT, Fib(C)) and some specialised coagulation tests (vWF, AT, Plasmin Inh). Despite these similarities, ovine secondary haemostasis demonstrated substantial differences to that of human. Rapid initiation of the contact activation pathway, high levels of FVIII, low Protein C, greater overall clot firmness and a reduced capacity for clot lysis was documented in sheep. In addition, ADP and collagen agonists precipitated a reduced primary haemostatic response in sheep relative to human. Intraspecies differences in whole blood platelet aggregometry between the cohorts of sheep indicate the need for breed-specific normal ranges. CONCLUSIONS The application of a board spectrum of coagulation assays has enabled elucidation of the similarities as well as differences between ovine and human coagulation. The new knowledge generated from this study will guide the design of future translational coagulation studies in ovine models.
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Affiliation(s)
- Samuel R Foley
- Critical Care Research Group, The University of Queensland and The Prince Charles Hospital, Brisbane, QLD, Australia.
| | - Connie Solano
- Pathology Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Gabriela Simonova
- Critical Care Research Group, The University of Queensland and The Prince Charles Hospital, Brisbane, QLD, Australia; Research and Development, Australian Red Cross Blood Service, Brisbane, QLD, Australia
| | | | - Robert J Bird
- Pathology Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia; School of Medicine, Griffith University, QLD, Australia
| | - John W Semple
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Denise E Jackson
- School of Medical Sciences, RMIT University, Bundoora, VIC, Australia
| | - Andreas Schibler
- Mater Children's Hospital Mater, The University of Queensland, Brisbane, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The University of Queensland and The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Yoke Lin Fung
- Critical Care Research Group, The University of Queensland and The Prince Charles Hospital, Brisbane, QLD, Australia; School of Health and Sports Science, University of Sunshine Coast, Sippy Downs, QLD, Australia
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de Lange N, van Rheenen-Flach L, Lancé M, Mooyman L, Woiski M, van Pampus E, Porath M, Bolte A, Smits L, Henskens Y, Scheepers H. Peri-partum reference ranges for ROTEM ® thromboelastometry. Br J Anaesth 2014; 112:852-9. [DOI: 10.1093/bja/aet480] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Olde Engberink RH, Kuiper GJ, Wetzels RJ, Nelemans PJ, Lance MD, Beckers EA, Henskens YM. Rapid and Correct Prediction of Thrombocytopenia and Hypofibrinogenemia With Rotational Thromboelastometry in Cardiac Surgery. J Cardiothorac Vasc Anesth 2014; 28:210-6. [DOI: 10.1053/j.jvca.2013.12.004] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Indexed: 12/14/2022]
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Görlinger K, Shore-Lesserson L, Dirkmann D, Hanke AA, Rahe-Meyer N, Tanaka KA. Management of hemorrhage in cardiothoracic surgery. J Cardiothorac Vasc Anesth 2014; 27:S20-34. [PMID: 23910533 DOI: 10.1053/j.jvca.2013.05.014] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bleeding is an important issue in cardiothoracic surgery, and about 20% of all blood products are transfused in this clinical setting worldwide. Transfusion practices, however, are highly variable among different hospitals and more than 25% of allogeneic blood transfusions have been considered inappropriate. Furthermore, both bleeding and allogeneic blood transfusion are associated with increased morbidity, mortality, and hospital costs. In the past decades, several attempts have been made to find a universal hemostatic agent to ensure hemostasis during and after cardiothoracic surgery. Most drugs studied in this context have either failed to reduce bleeding and transfusion requirements or were associated with severe adverse events, such as acute renal failure or thrombotic/thromboembolic events and, in some cases, increased mortality. Therefore, an individualized goal-directed hemostatic therapy ("theranostic" approach) seems to be more appropriate to stop bleeding in this complex clinical setting. The use of point-of-care (POC) transfusion and coagulation management algorithms guided by viscoelastic tests such as thromboelastometry/thromboelastography in combination with POC platelet function tests such as whole blood impedance aggregometry, and based on first-line therapy with fibrinogen and prothrombin complex concentrate have been associated with reduced allogeneic blood transfusion requirements, reduced incidence of thrombotic/thromboembolic and transfusion-related adverse events, and improved outcomes in cardiac surgery. This article reviews the current literature dealing with the management of hemorrhage in cardiothoracic surgery based on POC diagnostics and with specific coagulation factor concentrates and its impact on transfusion requirements and patients' outcomes.
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Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
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82
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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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83
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Fassl J, Matt P, Eckstein F, Filipovic M, Gregor M, Zenklusen U, Seeberger MD, Bolliger D. Transfusion of Allogeneic Blood Products in Proximal Aortic Surgery With Hypothermic Circulatory Arrest: Effect of Thromboelastometry-Guided Transfusion Management. J Cardiothorac Vasc Anesth 2013; 27:1181-8. [DOI: 10.1053/j.jvca.2013.02.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Indexed: 11/11/2022]
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84
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Ogawa S, Ohnishi T, Hosokawa K, Szlam F, Chen E, Tanaka K. Haemodilution-induced changes in coagulation and effects of haemostatic components under flow conditions †. Br J Anaesth 2013; 111:1013-23. [DOI: 10.1093/bja/aet229] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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85
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Thorson CM, Van Haren RM, Ryan ML, Curia E, Sleeman D, Levi JU, Livingstone AS, Proctor KG. Pre-existing hypercoagulability in patients undergoing potentially curative cancer resection. Surgery 2013; 155:134-44. [PMID: 24238121 DOI: 10.1016/j.surg.2013.06.053] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 06/28/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rotational thromboelastometry (ROTEM) is a new point-of-care test that allows a rapid and comprehensive evaluation of coagulation. We were among the first to show that ROTEM identifies baseline hypercoagulability in 40% of patients with intra-abdominal malignancies and that hypercoagulability persists for ≥1 month after resection. The purpose of this follow-up study was to confirm and extend these observations to a larger population in outpatient preoperative clinics. The hypothesis is that pre-existing hypercoagulability is present in patients undergoing surgery for malignant disease and that coagulation status varies by tumor type. METHODS After informed consent, preoperative blood samples were drawn from patients undergoing exploratory laparotomies for intra-abdominal malignancies and analyzed with ROTEM. RESULTS Eighty-two patients were enrolled, including 72 with a confirmed pathologic diagnosis and 10 age-matched controls with benign disease. The most common cancers involved the pancreas (n = 23; 32%), esophagus (n = 19; 26%), liver (n = 12; 17%), stomach (n = 7; 10%), and bile ducts (n = 5; 7%). Preoperative hypercoagulability was detected in 31% (n = 22); these patients were more likely to have lymphovascular invasion (88% vs 50%; P = .011), perineural invasion (77% vs 36%; P = .007), and stage III/IV disease (80% vs 62%; P = .039). More patients with pancreatic tumors (9/23, 39%) were hypercoagulable than with esophageal (3/19, 16%) or liver (2/13, 15%, P = .034) tumors. When only resectable malignancies were considered, clot formation was more rapid (low clot formation time, high alpha) with enhanced maximum clot strength (high maximum clot firmness) in pancreatic versus esophageal or liver cancers and in all cancers versus those with benign disease. CONCLUSION Preoperative hypercoagulability can be identified with ROTEM and is associated with lymphovascular/perineural invasion and advanced-staged disease in cancer. Compared with other tumor types, pancreatic adenocarcinomas have the greatest risk for hypercoagulability.
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Affiliation(s)
- Chad M Thorson
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Robert M Van Haren
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Mark L Ryan
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Emiliano Curia
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Danny Sleeman
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Joe U Levi
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Alan S Livingstone
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Kenneth G Proctor
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL.
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86
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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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87
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Faraoni D, Savan V, Levy JH, Theusinger OM. Goal-directed coagulation management in the perioperative period of cardiac surgery. J Cardiothorac Vasc Anesth 2013; 27:1347-54. [PMID: 24103717 DOI: 10.1053/j.jvca.2013.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Indexed: 01/15/2023]
Affiliation(s)
- David Faraoni
- Department of Anesthesiology, Queen Fabiola Children's University Hospital (QFCUH), Free University of Brussels, Brussels, Belgium.
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88
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Bolliger D, Tanaka KA. Roles of thrombelastography and thromboelastometry for patient blood management in cardiac surgery. Transfus Med Rev 2013; 27:213-20. [PMID: 24075802 DOI: 10.1016/j.tmrv.2013.08.004] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 12/28/2022]
Abstract
The value of thrombelastography (TEG) and thromboelastometry (ROTEM) to improve perioperative hemostasis is under debate. We aimed to assess the effects of TEG- or ROTEM-guided therapy in patients undergoing cardiac surgery on the use of allogeneic blood products. We analyzed 12 trials including 6835 patients, 749 of them included in 7 randomized controlled trials (RCTs). We collected data on the amount of transfused allogeneic blood products and on the proportion of patients who received allogeneic blood products or coagulation factor concentrates. Including all trials, the odds ratios (ORs) for transfusion of red blood cell (RBC) concentrates, fresh-frozen plasma (FFP), and platelets were 0.62 (95% confidence interval [CI], 0.56-0.69; P<.001), 0.28 (95% CI, 0.24-0.33; P<.001), and 0.55 (95% CI, 0.49-0.62; P<.001), respectively. However, more than 50% of the patients in this analysis were derived from one retrospective study. Including RCTs only, the ORs for transfusion of RBC, FFP, and platelets were 0.54 (95% CI, 0.38-0.77; P<.001), 0.36 (95% CI, 0.25-0.53; P<.001), and 0.57 (95% CI, 0.39-0.81; P=.002), respectively. The use of coagulation factor concentrates was reported in 6 studies, 2 of them were RCTs. The ORs for the infusion of fibrinogen and prothrombin complex concentrate were 1.56 (95% CI, 1.29-1.87; P<.001) and 1.74 (95% CI, 1.40-2.18; P<.001), respectively. However, frequencies and amounts were similar in the intervention and control group in the 2 RCTs. It is presumed that TEG- or ROTEM-guided hemostatic management reduces the proportion of patients undergoing cardiac surgery transfused with RBC, FFP, and platelets. This presumption is strongly supported by similar ORs found in the analysis including RCTs only. Patient blood management based on the transfusion triggers by TEG or ROTEM appears to be more restrictive than the one based on conventional laboratory testing. However, evidence for improved clinical outcome is limited at this time.
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Affiliation(s)
- Daniel Bolliger
- Department of Anesthesia and Intensive Care Medicine, University Hospital, Basel, Switzerland.
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89
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Abstract
PURPOSE OF REVIEW On the one hand, cardiac and aortic surgery is associated with a high rate of allogeneic blood transfusion. On the other hand, both bleeding and allogeneic blood transfusion is associated with increased morbidity, mortality, and hospital costs in cardiac and aortic surgery. This article reviews the current literature between 1995 and 2012 dealing with transfusion protocols in cardiovascular surgery. The 16 studies fitting these search criteria have evaluated the impact of the implementation of ROTEM/TEG based coagulation management algorithms on transfusion requirement and outcome in overall 8507 cardiovascular surgical patients. RECENT FINDINGS The use of point-of-care (POC) transfusion and coagulation management algorithms based on viscoelastic tests such as thromboelastometry (ROTEM) and thrombelastography (TEG) in combination with POC platelet function tests such as whole blood impedance aggregometry (Multiplate) have been shown to be associated with reduced allogeneic blood transfusion requirements, reduced incidence of thrombotic/thromboembolic and transfusion-related adverse events, and improved outcomes in cardiac surgery. SUMMARY Implementation of POC algorithms including a comprehensive bundle of POC diagnostics (thromboelastometry and whole blood impedance aggregometry) in combination with first-line therapy using immediately available specific coagulation factor concentrates (fibrinogen and prothrombin complex concentrate) and defining strict indications, calculated dosages, and clear sequences for each haemostatic intervention seems to be complex but most effective in reducing perioperative transfusion requirements and has been shown to be associated with a decreased incidence of thrombotic/thromboembolic events, transfusion-related adverse events, as well as with improved patients' outcomes including 6-month mortality.
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90
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High haematocrit in cyanotic congenital heart disease affects how fibrinogen activity is determined by rotational thromboelastometry. Thromb Res 2013; 132:e145-51. [DOI: 10.1016/j.thromres.2013.07.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 06/18/2013] [Accepted: 07/09/2013] [Indexed: 01/08/2023]
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91
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Tanaka KA, Bader SO, Sturgil EL. Diagnosis of Perioperative Coagulopathy—Plasma versus Whole Blood Testing. J Cardiothorac Vasc Anesth 2013; 27:S9-15. [DOI: 10.1053/j.jvca.2013.05.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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92
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Theusinger OM, Schröder CM, Eismon J, Emmert MY, Seifert B, Spahn DR, Baulig W. The Influence of Laboratory Coagulation Tests and Clotting Factor Levels on Rotation Thromboelastometry (ROTEM®) During Major Surgery with Hemorrhage. Anesth Analg 2013; 117:314-21. [DOI: 10.1213/ane.0b013e31829569ac] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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93
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94
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Dietrich W, Busley R, Spannagl M, Braun S, Schuster T, Lison S. The Influence of Antithrombin Substitution on Heparin Sensitivity and Activation of Hemostasis During Coronary Artery Bypass Graft Surgery. Anesth Analg 2013; 116:1223-30. [DOI: 10.1213/ane.0b013e31827d0f6b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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95
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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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96
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Practical application of point-of-care coagulation testing to guide treatment decisions in trauma. J Trauma Acute Care Surg 2013; 74:1587-98. [DOI: 10.1097/ta.0b013e31828c3171] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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97
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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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98
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Hoffman M, Cichon LJH. Practical coagulation for the blood banker. Transfusion 2013; 53:1594-602. [PMID: 23560738 DOI: 10.1111/trf.12201] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Revised: 02/22/2013] [Accepted: 02/25/2013] [Indexed: 12/29/2022]
Affiliation(s)
- Maureane Hoffman
- Department of Pathology, Duke University Medical Center and Durham Veterans Affairs Medical Center, Durham, NC, USA.
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Persistence of Hypercoagulable State after Resection of Intra-Abdominal Malignancies. J Am Coll Surg 2013; 216:580-9; discussion 589-90. [DOI: 10.1016/j.jamcollsurg.2012.12.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 12/07/2012] [Indexed: 11/23/2022]
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100
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Leal-Noval SR, Muñoz M, Asuero M, Contreras E, García-Erce JA, Llau JV, Moral V, Páramo JA, Quintana M, Basora M, Bautista-Paloma FJ, Bisbe E, Bóveda JL, Castillo-Muñoz A, Colomina MJ, Fernández C, Fernández-Mondéjar E, Ferrándiz C, García de Lorenzo A, Gomar C, Gómez-Luque A, Izuel M, Jiménez-Yuste V, López-Briz E, López-Fernández ML, Martín-Conde JA, Montoro-Ronsano B, Paniagua C, Romero-Garrido JA, Ruiz JC, Salinas-Argente R, Sánchez C, Torrabadella P, Arellano V, Candela A, Fernández JA, Fernández-Hinojosa E, Puppo A. [The 2013 Seville Consensus Document on alternatives to allogenic blood transfusion. An update on the Seville Document]. Med Intensiva 2013; 37:259-83. [PMID: 23507335 DOI: 10.1016/j.medin.2012.12.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 12/12/2012] [Accepted: 12/19/2012] [Indexed: 02/06/2023]
Abstract
Since allogeneic blood transfusion (ABT) is not harmless, multiple alternatives to ABT (AABT) have emerged, though there is great variability in their indications and appropriate use. This variability results from the interaction of a number of factors, including the specialty of the physician, knowledge and preferences, the degree of anemia, transfusion policy, and AABT availability. Since AABTs are not harmless and may not meet cost-effectiveness criteria, such variability is unacceptable. The Spanish Societies of Anesthesiology (SEDAR), Hematology and Hemotherapy (SEHH), Hospital Pharmacy (SEFH), Critical Care Medicine (SEMICYUC), Thrombosis and Hemostasis (SETH) and Blood Transfusion (SETS) have developed a Consensus Document for the proper use of AABTs. A panel of experts convened by these 6 Societies have conducted a systematic review of the medical literature and have developed the 2013 Seville Consensus Document on Alternatives to Allogeneic Blood Transfusion, which only considers those AABT aimed at decreasing the transfusion of packed red cells. AABTs are defined as any pharmacological or non-pharmacological measure aimed at decreasing the transfusion of red blood cell concentrates, while preserving patient safety. For each AABT, the main question formulated, positively or negatively, is: « Does this particular AABT reduce the transfusion rate or not?» All the recommendations on the use of AABTs were formulated according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.
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Affiliation(s)
- S R Leal-Noval
- Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias.
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