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Michel S, Piekarski F, Fischer JH, Hettler V, Adam EH, Holzer L, Lotz G, Walther T, Zacharowski K, Raimann FJ. Hemostatis Analyzer-Supported Hemotherapy Algorithm in Cardiac Surgery: Protocol for a Randomized Controlled Monocentric Trial. JMIR Res Protoc 2020; 9:e17206. [PMID: 32314972 PMCID: PMC7201313 DOI: 10.2196/17206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/04/2020] [Accepted: 01/07/2020] [Indexed: 11/30/2022] Open
Abstract
Background Point of care devices for performing targeted coagulation substitution in patients who are bleeding have become increasingly important in recent years. New on the market is the Quantra. It is a device that uses sonorheometry, a sonic estimation of elasticity via resonance, which is a novel ultrasound-based technology that measures viscoelastic properties of whole blood. Several studies have already shown the comparability of the Quantra with devices already established on the market, such as the rotational thromboelastometry (ROTEM) device. Objective In contrast to existing studies, this study is the first prospective interventional study using this new system in a cardiac surgical patient cohort. We will investigate the noninferiority between an already existing coagulation algorithm based on the ROTEM/Multiplate system and a new algorithm based on the Quantra system for the treatment of coagulopathic cardiac surgical patients. Methods The study is divided into two phases. In an initial observation phase, whole blood samples of 20 patients obtained at three defined time points (prior to surgery, after completion of cardiopulmonary bypass, and on arrival in the intensive care unit) will be analyzed using both the ROTEM/Multiplate and Quantra systems.
The obtained threshold values will be used to develop a novel algorithm for hemotherapy. In a second intervention phase, the new algorithm will be tested for noninferiority against an algorithm used routinely for years in our department. Results The main objective of the examination is the cumulative loss of blood within 24 hours after surgery. Statistical calculations based on the literature and in-house data suggest that the new algorithm is not inferior if the difference in cumulative blood loss is <150 mL/24 hours. Conclusions Because of the comparability of the Quantra sonorheometry system with the ROTEM measurement methods, the existing hemotherapy treatment algorithm can be adapted to the Quantra device with proof of noninferiority. Trial Registration ClinicalTrials.gov NCT03902275; https://clinicaltrials.gov/ct2/show/NCT03902275 International Registered Report Identifier (IRRID) DERR1-10.2196/17206
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Affiliation(s)
- Sophie Michel
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Florian Piekarski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Jan-Hendrik Fischer
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Vanessa Hettler
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Elisabeth Hannah Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Lars Holzer
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Gösta Lotz
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Thomas Walther
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Florian Jürgen Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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Multicenter Evaluation of the Quantra QPlus System in Adult Patients Undergoing Major Surgical Procedures. Anesth Analg 2020; 130:899-909. [DOI: 10.1213/ane.0000000000004659] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Ranucci M, Di Dedda U, Baryshnikova E. Trials and Tribulations of Viscoelastic-Based Determination of Fibrinogen Concentration. Anesth Analg 2020; 130:644-653. [DOI: 10.1213/ane.0000000000004522] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Ranucci M, Baryshnikova E. Sensitivity of Viscoelastic Tests to Platelet Function. J Clin Med 2020; 9:E189. [PMID: 32284512 PMCID: PMC7019879 DOI: 10.3390/jcm9010189] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 12/28/2019] [Accepted: 01/07/2020] [Indexed: 12/02/2022] Open
Abstract
Viscoelastic tests provide a dynamic assessment of coagulation, by exploring the time to clot formation and the clot strength. Using specific activators or inhibitors, additional factors can be explored, like the fibrinogen contribution to clot strength. Since the early days, various attempts have been done to measure platelet function with viscoelastic test. In general, the difference between the maximum clot strength and the fibrinogen contribution is considered an index of platelet contribution. However, this parameter does not clearly split platelet count from function; additionally, the extensive thrombin generation of standard activated viscoelastic tests activates platelet through the protease activated receptors, bypassing the other pathways. For this reason, standard viscoelastic tests cannot be used to assess platelet reactivity under the effects of aspirin or P2Y12 inhibitors. To overcome this limitation, a specific test was developed (thromboelastography platelet mapping). This test has been compared with the gold standard of light transmission aggregometry and with other point-of-care tests, with conflicting results. In general, the use of viscoelastic tests to assess the effects of antiplatelet agents is still limited. Conversely, platelet contribution to clot strength in the setting of coagulopathic bleeding is considered an important parameter to trigger platelet transfusion or desmopressin.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, 20097 Milan, Italy;
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El-Khawas K, Lloyd-Donald P, Hart GK, Gonzalvo A, Smith C, Eastwood GM, Bellomo R. Prospective Longitudinal Evaluation of Coagulation with Novel Thromboelastography Technology in Patients After Subarachnoid Hemorrhage: A Pilot Study. World Neurosurg 2019; 136:e181-e195. [PMID: 31887461 DOI: 10.1016/j.wneu.2019.12.109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is limited knowledge of whether hypercoagulability is present after subarachnoid hemorrhage (SAH) or about its timing of onset, duration, and severity. To conduct a pilot new-generation thromboelastography (TEG) technology (TEG6s)-based and conventional coagulation test-supported longitudinal assessment of coagulation in patients with SAH. METHODS We prospectively enrolled patients with nontraumatic SAH on admission from May 2015 to May 2016. We performed TEG6s measurements and conventional coagulation tests on days 1, 2, 3, 5, 7, 10, and 14 and compared them with TEG6s parameters in healthy volunteers. RESULTS We studied 14 patients and 72 TEG6s measurements. Of these patients, 10 (71.4%) were admitted to the intensive care unit. Mean age was 57.5 (±14.5) years, Acute Physiology and Chronic Health Evaluation III score 58.2 (±26.6), length of hospital stay was 23 (±11.7) days, and mortality was 14.3%. At baseline, conventional coagulation tests were within normal range. However, TEG6s parameters already showed increased coagulability. Thereafter, alpha angle, reaction time, functional fibrinogen level, and maximum amplitude rapidly and significantly increased (P < 0.01) compared with healthy controls. Ten (71.4%) patients demonstrated a >20% increase in coagulability based on TEG6s parameters from their baseline. Moreover, TEG6s hypercoagulability peaked at day 10 and only showed an initial partial decline towards normal by day 14. Similarly, platelet counts and fibrinogen levels increased over this period (P < 0.01) CONCLUSIONS: Using TEG6s technology, we found significant and progressive hypercoagulability in 70% of patients, with an early dominant contribution from hyperfibrinogenemia and increased fibrin formation and partial contribution from thrombocytosis, beginning on the first day, increasing to peak values by day 10, and then partly declining toward normal by day 14.
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Affiliation(s)
- Khaled El-Khawas
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, Australia.
| | | | - Graeme K Hart
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Health and BioMedical Informatics Centre, The University of Melbourne, Melbourne, Australia
| | - Augusto Gonzalvo
- Department of Neurosurgery, Austin Hospital, Melbourne, Australia
| | - Carole Smith
- Department of Haematology, Austin Hospital, Melbourne, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia; Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
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Methods for measurement of platelet function in the assessment of nonclinical drug safety and implications for translatability. CURRENT OPINION IN TOXICOLOGY 2019. [DOI: 10.1016/j.cotox.2019.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Lauridsen SV, Hvas CL, Sandgaard E, Gyldenholm T, Mikkelsen R, Obbekjær T, Sunde N, Tønnesen EK, Hvas AM. Thromboelastometry Shows Early Hypercoagulation in Patients with Spontaneous Subarachnoid Hemorrhage. World Neurosurg 2019; 130:e140-e149. [DOI: 10.1016/j.wneu.2019.06.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 12/14/2022]
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Turner JS, Kutter APN, Sigrist NE. Correlation of rotational thromboelastometry (ROTEM) parameters with platelet count and their ability to predict thrombocytopenia in dogs. Res Vet Sci 2019; 126:45-50. [PMID: 31430579 DOI: 10.1016/j.rvsc.2019.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/18/2019] [Accepted: 08/04/2019] [Indexed: 10/26/2022]
Abstract
The study objectivs were to evaluate the correlation between platelet count (PLT) and rotational thromboelastometry (ROTEM) parameters and to determine ROTEM cut-off values for identification of thrombocytopenia in dogs. Medical records of 113 dogs with concurrent EXTEM (ROTEM activated by proprietary tissue factor), FIBTEM (EXTEM with added cytochalasin D) analysis and PLT were retrospectively reviewed. Signalment, treatment prior to analysis, hematocrit (HCT), EXTEM/FIBTEM maximum clot firmness (MCFEXTEM, MCFFIBTEM), EXTEM/FIBTEM maximum clot elasticity (MCEEXTEM, MCEFIBTEM) and EXTEM maximum lysis (MLEXTEM) were extracted from patient records and ROTEM database. Delta (Δ) MCF was calculated as MCFEXTEM-MCFFIBTEM and ΔMCE as MCEEXTEM-MCEFIBTEM. The PLT was correlated to MCFEXTEM, MCEEXTEM, ΔMCF and ΔMCE using Spearman-Rho analysis. Correlations were further analyzed in thrombocytopenic dogs. The ability to predict thrombocytopenia was evaluated with receiver operating characteristics (ROC). Thirty-seven samples (32.7%) showed thrombocytopenia (<130 × 109/L) and 19 samples (17%) severe thrombocytopenia (<60* x 109/L). The PLT significantly correlated with MCFEXTEM (r = 0.545, P < .001), MCEEXTEM (r = 0.547, P < .001), ΔMCF (r = 0.441, P < .001) and ΔMCE (r = 0.559, P < .001). MCFEXTEM < 49 mm, MCEEXTEM < 93, ΔMCF <42 mm and ΔMCE <90 predicted thrombocytopenia <60 × 109/L with a sensitivity of 90% and a specificity of 78% with a negative predictive value >97% for all 4 parameters. In conclusion, PLT in dogs correlated moderately but significantly with all evaluated ROTEM parameters. All parameters were able to rule out thrombocytopenia <60 × 109/L with a high negative predictive value, while the sensitivity to predict thrombocytopenia was only moderate and the positive predictive value was low.
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Affiliation(s)
- Jennifer S Turner
- Division of Critical Care Medicine, Department of Small Animals, Vetsuisse Faculty, University of Zurich, 8057 Zürich, Switzerland
| | - Annette P N Kutter
- Section of Anesthesiology, Department for Diagnostics and Clinical Services, Vetsuisse Faculty, University of Zurich, 8057 Zürich, Switzerland
| | - Nadja E Sigrist
- Division of Critical Care Medicine, Department of Small Animals, Vetsuisse Faculty, University of Zurich, 8057 Zürich, Switzerland.
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The Influence of Inflammation on Fibrinogen Turnover and Redistribution of the Hemostatic Balance to a Prothrombotic State in High On-Treatment Platelet Reactivity-Dual Poor Responder (HTPR-DPR) Patients. Mediators Inflamm 2019; 2019:3767128. [PMID: 31396017 PMCID: PMC6664506 DOI: 10.1155/2019/3767128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/11/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022] Open
Abstract
Knowledge about the influence of inflammation on platelet function and relocation of hemostatic balance to hypercoagulable state is still unclear. We compared two groups of patients who suffer from acute vs. chronic inflammatory process and additionally present high on-treatment platelet reactivity-dual platelet resistance. We did not found any differences in platelet aggregation between both investigated groups, but patients who suffer from chronic inflammation presented stronger relocation of the hemostatic balance to the hypercoagulability. A high concentration of prothrombin fragment F1+2 together with higher activity of von Willebrand factor in critical limb ischemia shows more exaggerated fibrinogen turnover although the blood concentration of this factor was in normal range. We concluded that high on-treatment platelet reactivity-dual platelet resistance and intensified inflammation are linked with elevated platelet and fibrinogen turnover to counteract proper hemostatic balance in favor of a prothrombotic state.
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Rotational thromboelastometry assessment of ballanced crystalloid, hydroxyethyl starch and gelatin effects on coagulation: a randomized trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31405567 PMCID: PMC9391864 DOI: 10.1016/j.bjane.2019.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background and objectives Methods Results Conclusion
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Sevcikova S, Durila M, Vymazal T. Tromboelastometria rotacional na avaliação dos efeitos de cristaloides balanceados, hidroxietilamido e gelatina na coagulação: estudo randômico. Braz J Anesthesiol 2019; 69:383-389. [DOI: 10.1016/j.bjan.2019.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/04/2019] [Accepted: 03/17/2019] [Indexed: 12/21/2022] Open
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Baryshnikova E, Di Dedda U, Ranucci M. A Comparative Study of SEER Sonorheometry Versus Standard Coagulation Tests, Rotational Thromboelastometry, and Multiple Electrode Aggregometry in Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:1590-1598. [DOI: 10.1053/j.jvca.2019.01.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Indexed: 11/11/2022]
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Bolliger D, Tanaka KA. Platelet Count and Function—Can We Kill Two Birds With an Ultrasound Wave? J Cardiothorac Vasc Anesth 2019; 33:1599-1600. [DOI: 10.1053/j.jvca.2019.02.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 02/19/2019] [Indexed: 11/11/2022]
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Raveh Y, Souki F, Livingstone J, Beduschi T, Vianna R, Rodriguez Y, Nicolau-Raducu R. Fibrinolytic Shutdown Is Associated With Intraoperative Thrombosis and Hemorrhage During Visceral Transplant. Semin Cardiothorac Vasc Anesth 2019; 23:300-308. [DOI: 10.1177/1089253219848441] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Objective. End-stage liver disease is characterized by a precarious imbalance of hemostasis. Detrimental consequences of hypofibrinolysis, also known as fibrinolytic shutdown, have been recently demonstrated, and its significance in visceral (ie, an allograft that contains the intestine) transplant remains unknown. Design and Setting. To fill this gap, following institutional review board approval, this retrospective study included 49 adult recipients of visceral allografts (14 “visceral allograft without the liver” and 35 “multivisceral” with the liver) transplanted between 2010 and 2018 in a single university hospital, and for whom pre-incisional thromboelastography was available. Based on percent clot lysis 30 minutes after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: fibrinolytic shutdown, physiologic fibrinolysis, and hyperfibrinolysis. Results. Fibrinolytic shutdown occurred in 57% of patients, with higher incidence in recipients of multivisceral transplant (69%) compared with visceral allograft without liver (29%) allografts ( P = .04). Fibrinolytic shutdown was associated with an increase in both intraoperative thrombosis and hemorrhage. Intraoperative thrombosis (18%) occurred only with multivisceral transplant, and accounted for 36% of in-hospital mortality. A clinically meaningful reduction in incidence of intraoperative thrombosis was noted in recipients who received intravenous heparin thromboprophylaxis. Logistic regression identified pretransplant platelet count as a risk factor for fibrinolytic shutdown (odds ratio = 0.992, 95% confidence interval = [0.984-0.998]; χ2= 7.8, P = .005). Conclusions. This study highlights fibrinolytic shutdown as a dominant and clinically important feature of the hemostatic imbalance in recipients undergoing visceral transplantation.
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Affiliation(s)
- Yehuda Raveh
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Fouad Souki
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | | | - Thiago Beduschi
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Rodrigo Vianna
- University of Miami/Jackson Memorial Hospital, Miami, FL, USA
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Liebrecht LK, Newton J, Martin EJ, Wickramaratne N, Jayaraman S, Han J, Aboutanos M, Brophy DF, Mangino MJ. Effects of a novel low volume resuscitation solutions on coagulation and platelet function. PLoS One 2019; 14:e0215386. [PMID: 31042735 PMCID: PMC6493729 DOI: 10.1371/journal.pone.0215386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/01/2019] [Indexed: 11/18/2022] Open
Abstract
Background Novel crystalloid solutions containing polyethylene glycol polymers (PEG-20k) produce dramatic resuscitation effects but dose-dependently produce a hypocoagulative state. The objective of this study was to examine possible mechanisms of this effect. Based on previous thromboelastography data, we hypothesize the effect is largely due to platelet interactions with the polymers. Methods Whole citrated blood from healthy volunteers was diluted ex-vivo 10% with crystalloids and tested for coagulation and platelet function. The specific tests included prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and von Willebrand factor (vWf) activity, thrombin generation, thromboelastography with and without platelet mapping, platelet flow cytometry, and erythrocyte sedimentation rate. Findings Fibrinogen and vWF activities, PT, and aPTT were not affected by PEG-20k dilutions. Thrombin activity was mildly suppressed with PEG-20k (TTP- 20%). Platelet mapping demonstrated significantly greater % inhibition of both ADP and arachidonic acid-induced platelet aggregation with PEG-20k, but direct ADP-activated gpIIa/IIIb (PAC1) and P-selectin (CD62P) binding site expression was not altered. Mild dose-dependent suppression of TEG-MA was seen with PEG-20k using platelet poor plasma. Erythrocyte Sedimentation Rates (ESR) were dramatically accelerated after dilution with 10% PEG-20k, which was competitively blocked by smaller PEG polymers, suggesting nonspecific PEG-20k cell binding effects. Conclusions PEG-20k creates a mild hypocoagulative state in whole blood at concentrations ≥10%, which may be due to platelet-PEG interactions at the IIb/IIIa interface with lesser effects on fibrin polymerization. This interaction may cause a functional thrombasthenia induced by nonspecific platelet surface passivation by the PEG polymer.
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Affiliation(s)
- Loren K. Liebrecht
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Jason Newton
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Erika J. Martin
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, United States of America
| | - Niluka Wickramaratne
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Sudha Jayaraman
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Jinfeng Han
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Michel Aboutanos
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Donald F. Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA, United States of America
| | - Martin J. Mangino
- Department of Surgery, Division of Acute Care Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
- Department of Physiology and Biophysics, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
- Department of Emergency Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
- * E-mail:
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Thromboelastometry as a diagnostic tool in mild bleeding disorders: A prospective cohort study. Eur J Anaesthesiol 2019; 36:457-465. [PMID: 30950901 DOI: 10.1097/eja.0000000000000985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Major guidelines emphasise the potential of visco-elastic methods to overcome the limitations of conventional laboratory assays in the peri-operative setting. Their sensitivity regarding mild bleeding disorders (MBDs), the most common bleeding disorders in the general population, is however unknown. OBJECTIVE The aim of this study was to investigate the sensitivity of thromboelastometry for diagnosis of MBD. DESIGN A single-centre prospective cohort study. SETTING Haematology outpatient unit of a tertiary general hospital in Central Switzerland. PATIENTS All consecutive patients referred over a 32-month period with a suspected bleeding disorder were included and thromboelastometry was conducted using a ROTEM delta (EXTEM, INTEM and FIBTEM). Diagnostic work-up was performed according to current guidelines including the ISTH bleeding assessment tool (ISTH BAT). MAIN OUTCOME MEASURES Distribution of clotting time (CT) and maximum clot firmness (MCF) results in relation to the presence of MBD. RESULTS Two hundred and seventeen patients were assessed; the median [IQR] age was 39 years [28 to 57]; 151 patients were women (70%). MBD was diagnosed in 97 patients (45%), no MBD was found in 100 patients (46%) and a systemic disorder recognised in 20 patients (9%). Presence of MBD was not associated with a significant difference in thromboelastometry variables (0.2 s in CT EXTEM, 95% CI -2.3 to 2.7; -0.2 mm in MCF EXTEM, 95% CI -1.8 to 1.5; -0.7 s in CT INTEM, 95% CI -12.6 to 11.2; 0.6 mm in MCF INTEM, 95% CI -1.2 to 1.3; 0.8 mm in MCF FIBTEM, 95% CI -1.6 to 1.4) and most results were within the established reference ranges. CONCLUSION Our data did not support the use of thromboelastometry as a diagnostic tool in patients with MBD.
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Abstract
Platelet contraction provides a minimally invasive source for physiologic information. In this article, we describe a device that directly measures the kinetics of platelet contraction. Whole blood is injected between acrylic plates and an adherent clot forms. The bottom plate is fixed, and the top plate is attached to a wire cantilever. Platelet contraction drives deflection of the wire cantilever which is captured by a camera. Force generated by the clot with time is derived using beam equations. Force derivations were verified using a microelectromechanical (MEMS) force sensor. Kinetics of clot contraction were defined, including maximum contraction force (FMAX), lift-off time (TLIFTOFF), and contraction rate (CR). Metrics were compared with optical aggregometry and thromboelastography. FMAX correlates with optical aggregometry maximal amplitude with a Spearman's rho of 0.7904 and p = 0.0195 and thromboelastography maximal amplitude with a Spearman's rho of 0.8857 and p = 0.0188. Lift-off time correlates with optical aggregometry lag time with a Spearman's rho of 0.9048 and p = 0.002. This preliminary study demonstrates the repeatability of a useful platelet contraction device and its correlation with thromboelastography and optical aggregometry, the gold standard platelet function test.
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Ranucci M, Di Dedda U, Baryshnikova E. Platelet Contribution to Clot Strength in Thromboelastometry: Count, Function, or Both? Platelets 2019; 31:88-93. [DOI: 10.1080/09537104.2019.1581920] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Marco Ranucci
- Department Of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Umberto Di Dedda
- Department Of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Ekaterina Baryshnikova
- Department Of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Lauridsen SV, Hvas AM, Sandgaard E, Gyldenholm T, Rahbek C, Hjort N, Tønnesen EK, Hvas CL. Coagulation Profile after Spontaneous Intracerebral Hemorrhage: A Cohort Study. J Stroke Cerebrovasc Dis 2018; 27:2951-2961. [PMID: 30072172 DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/14/2018] [Accepted: 06/17/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) causes death or disability and the incidence increases with age. Knowledge of acute hemostatic function in patients with ICH without anticoagulant and antiplatelet therapy is sparse. Increased knowledge of the coagulation profile in the acute phase of ICH could improve acute treatment and recovery. We investigated coagulation at admission and changes in coagulation during the first 24hours after symptom onset. METHODS Enrolled were 41 ICH patients without anticoagulant or antiplatelet therapy admitted to Aarhus University Hospital, Denmark. Blood samples were collected at admission, 6, and 24hours after symptom onset. Thromboelastometry (ROTEM), thrombin generation, and thrombin-antithrombin (TAT) complex were analyzed. Clinical outcome was evaluated using the National Institute of Health Stroke Scale, the Modified Rankin Score, and mortality. RESULTS At admission, compared with healthy individuals, ICH patients had increased maximum clot firmness (EXTEM P < .0001; INTEM P < .0001; FIBTEM P < .0001), increased platelet maximum clot elasticity (P < .0001) in ROTEM, higher peak thrombin (P < .0001) and endogenous thrombin potential (P = .01) in thrombin generation, and elevated TAT complex levels. During 24hours after significantly, while thrombin generation showed decreased peak thrombin (P < .0001) and endogenous thrombin potential (P < .0001). Coagulation test results did not differ between patients when stratified according to clinical outcome. CONCLUSIONS ICH patients without anticoagulant or antiplatelet therapy demonstrated activated coagulation at admission and within 24hours after symptom onset.
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Affiliation(s)
| | - Anne-Mette Hvas
- Center for Hemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University, Hospital, Aarhus, Denmark
| | - Emilie Sandgaard
- Center for Hemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University, Hospital, Aarhus, Denmark
| | - Tua Gyldenholm
- Center for Hemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University, Hospital, Aarhus, Denmark
| | - Christian Rahbek
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Hjort
- Department of Neurology, Danish Stroke Center, Aarhus University Hospital, Aarhus, Denmark
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Effects of Fibrinogen Levels and Platelet Counts on Viscoelastic Testing in Cirrhotic Patients. ACTA ACUST UNITED AC 2018; 4:90-95. [PMID: 30582001 PMCID: PMC6294986 DOI: 10.2478/jccm-2018-0012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/02/2018] [Indexed: 12/12/2022]
Abstract
Introduction Cirrhotic patients have been considered for decades to have a pro-haemorrhagic pattern and were treated as such based on the results from standard coagulation tests. The aim of our study was to determine the effects of platelet count and fibrinogen levels on rotational thromboelastometry (ROTEM) parameters. Methods We prospectively included 176 patients with End-Stage Liver Disease (ESLD) admitted to our Intensive Care Unit prior to liver transplantation. Collected data consisted of severity scores, liver, renal and standard coagulation tests, fibrinogen levels, platelet counts and ROTEM parameters. Four ROTEM assays were performed (ExTEM, InTEM, ApTEM and FibTEM) and the following parameters included: CT - clotting time, CFT - clot formation time, MCF - maximum clot firmness, ML - maximum lysis, alpha angle, TPI - thrombin potential index, MaxV - maximum velocity of clot formation (MaxV), MaxVt - time to MaxV, MCE - maximum clot elasticity and AUC - area under the curve. Results Statistical analysis demonstrated a linear correlation between platelet counts and ExTEM TPI (R2 linear =0.494), ExTEM MaxV (R2 linear =0.253), ExTEM MCE (R2 linear = 0.351) and ExTEM MCF (R2 cubic = 0.498). Fibrinogen levels correlated linearly with ExTEM MCF (R2 linear = 0.426), ExTEM TPI (R2 linear = 0.544), ExTEM MaxV (R2 linear = 0.332), ExTEM MCE (R2 linear = 0.395) and non-linearly with ExTEM CFT (R2 cubic = 0.475). Conclusion Fibrinogen levels and platelet counts had an important effect on both standard and derived ROTEM parameters. Further analysis is required in order to determine clinically oriented cut-off values below which severe coagulopathy would develop.
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Buell TJ, Taylor DG, Chen CJ, Naik BI. Letter to the Editor. Rotational thromboelastometry-guided transfusion protocol. J Neurosurg Spine 2018; 29:118-120. [DOI: 10.3171/2018.1.spine1845] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Shirozu K, Fujimura N, Karashima Y, Ikeda M, Kitada H, Okabe Y, Kurihara K, Henzan T, Hoka S. Effects of preoperative plasma exchange therapy with albumin replacement fluid on blood coagulation in patients undergoing ABO-incompatible living-donor kidney transplantation using rotational thromboelastometry. BMC Anesthesiol 2018; 18:68. [PMID: 29921231 PMCID: PMC6008919 DOI: 10.1186/s12871-018-0536-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/30/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND ABO-incompatible living-donor kidney transplantation (LDKT) requires immunotherapy and plasma exchange therapy (PEX). PEX with albumin replacement fluid reportedly decreases fibrinogen levels. However, no reports have described the effects of PEX with albumin replacement fluid on blood coagulation parameters and blood loss during the perioperative period. Therefore, we investigated the effects of preoperative PEX on blood coagulation parameters and blood loss during the perioperative period in patients undergoing ABO-incompatible LDKT as measured by rotational thromboelastometry (ROTEM®). METHODS Twenty-eight patients undergoing LDKT were divided into the PEX group (ABO incompatible with PEX, n = 13) and non-PEX group (ABO compatible without PEX, n = 15). ROTEM® parameters, standard laboratory test parameters, bleeding volume, and transfusion volume were compared between PEX and non-PEX group. MCEplatelet, which represents platelet contribution to clot strength and where "MCE" stands for maximum clot elasticity, was calculated from the difference in MCE between EXTEM and FIBTEM. RESULTS The bleeding volume during surgery and the intensive care unit (ICU) stay was significantly higher in the PEX than non-PEX group (p < 0.01). Maximum clot firmness (MCF) of EXTEM (MCFEXTEM), MCFFIBTEM, and MCEplatelet was significantly lower in the PEX than non-PEX group (p < 0.01). In the PEX group, the bleeding volume during surgery was very strongly correlated with the baseline MCFEXTEM and MCEplatelet, and the bleeding volume during the ICU stay was strongly correlated with the postoperative MCFEXTEM and MCEplatelet. CONCLUSIONS These results suggest that the increased blood loss in the PEX group during surgery and the ICU stay was associated with decreased platelet contribution to clot strength as measured by ROTEM®. TRIAL REGISTRATION UMIN-Clinical Trial Registry UMIN000018355 . Registered 21 July 2015.
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Affiliation(s)
- Kazuhiro Shirozu
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Naoyuki Fujimura
- Department of Anesthesiology, St. Mary's Hospital, Kurume, Japan
| | - Yuji Karashima
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mizuko Ikeda
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hidehisa Kitada
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kei Kurihara
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoko Henzan
- Center for Cellular and Molecular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Sumio Hoka
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Grant AL, Letson HL, Morris JL, McEwen P, Hazratwala K, Wilkinson M, Dobson GP. Tranexamic acid is associated with selective increase in inflammatory markers following total knee arthroplasty (TKA): a pilot study. J Orthop Surg Res 2018; 13:149. [PMID: 29914535 PMCID: PMC6006687 DOI: 10.1186/s13018-018-0855-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/05/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) is commonly used in orthopedic surgery to reduce excessive bleeding and transfusion requirements. Our aim was to examine if TXA was required in all osteoarthritis patients undergoing TKA surgery, and its possible effects on systemic inflammation and coagulation properties. METHODS Twenty-three patients (Oxford Score 22-29) were recruited consecutively; 12 patients received TXA before (IV, 1.2 g/90 kg) and immediately after surgery (intra-articular, 1.4 g/90 kg). Inflammatory mediators and ROTEM parameters were measured in blood at baseline, after the first bone-cut, immediately after surgery, and postoperative days 1 and 2. RESULTS After the bone cut and surgery, TXA significantly increased MCP-1, TNF-α, IL-1β and IL-6 levels compared to non-TXA patients, which was further amplified postoperatively. During surgery, TXA significantly prolonged EXTEM clot times, indicating a thrombin-slowing effect, despite little or no change in clot amplitude or fibrinogen. TXA was associated with three- to fivefold increases in FIBTEM maximum lysis (ML), a finding counter to TXA's antifibrinolytic effect. Maximum lysis for extrinsic and intrinsic pathways was < 8%, indicating little or no hyperfibrinolysis. No significant differences were found in postoperative hemoglobin between the two groups. CONCLUSIONS TXA was associated with increased systemic inflammation during surgery compared to non-TXA patients, with further amplification on postoperative days 1 and 2. On the basis of little or no change in viscoelastic clot strength, fibrinogen or clot lysis, there appeared to be no clinical justification for TXA in our group of patients. Larger prospective, randomized trials are required to investigate a possible proinflammatory effect in TKA patients.
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Affiliation(s)
- Andrea L Grant
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, Townsville, Queensland, 4812, Australia.,Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Hayley L Letson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Jodie L Morris
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, Townsville, Queensland, 4812, Australia.,Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Peter McEwen
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, Townsville, Queensland, 4812, Australia.,Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Kaushik Hazratwala
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, Townsville, Queensland, 4812, Australia.,Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Matthew Wilkinson
- The Orthopaedic Research Institute of Queensland (ORIQL), 7 Turner St, Pimlico, Townsville, Queensland, 4812, Australia.,Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia
| | - Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Townsville, Queensland, 4811, Australia.
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Abstract
: Thrombelastography Platelet Mapping (TEG-PM) allows for measurement of maximal potential clot strength (MA) and strength from stimulation of arachidonic acid (MA-AA) and adenosine disphosphate (MA-ADP) receptors. This study was conducted to assess degree of platelet dysfunction in critically ill adult patients. A retrospective study of critically ill, adult, nontrauma patients in a medical/surgical ICU was conducted from August 2013 to September 2014. All patients who underwent TEG-PM were enrolled. Patients with intracerebral hemorrhage, following cardiac surgery, or without an APACHE II score were excluded. Patients were divided into those with and without aspirin use. Demographics, APACHE II score, and laboratory results were abstracted. Student t test was used to test significance. A total of 79 patients were enrolled (61% male). Average age and APACHE II score were 61 ± 16 years and 18 ± 9, respectively. Factor-associated coagulation measures and MA were normal in all groups but MA-AA and MA-ADP were significantly reduced irrespective of anticoagulant use. Compared to the nonanticoagulated cohort, MA-AA was significantly reduced in those on aspirin. There was no difference in mortality or length of stay in any cohort. Inhibition of the AA and ADP pathways is common in critically ill patients. Clinical correlation with propensity for bleeding and need for transfusion requires further assessment.
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Cheng F, Yang Z, Zeng J, Gu J, Cui J, Ning J, Yi B. Anesthesia Management of Modified Ex Vivo Liver Resection and Autotransplantation. Ann Transplant 2018; 23:274-284. [PMID: 29700275 PMCID: PMC6248320 DOI: 10.12659/aot.907796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Ex situ liver surgery allows liver resection and vascular reconstruction in patients who have liver tumors located in critical sites. Only a small series of studies about ex situ liver surgery is available in the literature. No anesthesia management experience has been previously published. The aim of the currents study was to summarize our experience with anesthetic management of patients during ex vivo liver surgery. Material/Methods The first 43 patients who received ex vivo liver surgery between January 2007 and April 2012 were included. A pulmonary artery catheter (PAC), transesophageal echocardiography (TEE), and pulse indicator continuous cardiac output (PiCCO) were used intraoperatively in the patients to monitor the hemodynamic changes. Thromboelastogram and the plasma coagulation test were used to monitor the coagulation changes. Results All patients received general anesthesia with rapid sequence induction. The data obtained by PAC, TEE, and PiCOO in these cases showed large changes in hemodynamics during the stages of the first or second vessel reconstruction. The CI decreased about 59%/63% and the MPAP decreased about 49%/37% during the first/second vessel reconstruction. Accurate judgment of the dosage of active drug for vascular support is the key for the stabilization of hemodynamics as quickly as possible. However, a high incidence (35.5%) of prophase fibrinolysis in a long anhepatic phase should be monitored and managed. Conclusions Ex vivo liver surgery is no longer experimental and is a therapeutic option for patients with liver cancer in critical sites. Good anesthesia support is an essential element of liver autotransplantation.
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Affiliation(s)
- Fujun Cheng
- Department of Anesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Zhiyong Yang
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Jing Zeng
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Jianteng Gu
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Jian Cui
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Jiaoning Ning
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
| | - Bin Yi
- Department of Anaesthesia, Southwest Hospital, The Third Military Medical University (Army Medical University), Chongqing, China (mainland)
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George MJ, Bynum J, Nair P, Cap AP, Wade CE, Cox CS, Gill BS. Platelet biomechanics, platelet bioenergetics, and applications to clinical practice and translational research. Platelets 2018; 29:431-439. [PMID: 29580113 DOI: 10.1080/09537104.2018.1453062] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The purpose of this review is to explore the relationship between platelet bioenergetics and biomechanics and how this relationship affects the clinical interpretation of platelet function devices. Recent experimental and technological advances highlight platelet bioenergetics and biomechanics as alternative avenues for collecting clinically relevant data. Platelet bioenergetics drive energy production for key biomechanical processes like adhesion, spreading, aggregation, and contraction. Platelet function devices like thromboelastography, thromboelastometry, and aggregometry measure these biomechanical processes. Platelet storage, stroke, sepsis, trauma, or the activity of antiplatelet drugs alters measures of platelet function. However, the specific mechanisms governing these alterations in platelet function and how they relate to platelet bioenergetics are still under investigation.
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Affiliation(s)
- Mitchell J George
- a Department of Surgery, McGovern Medical School , The University of Texas Health Science Center , Houston , TX , USA
| | - James Bynum
- c Coagulation & Blood Research, US Army Institute of Surgical Research, JBSA Fort , Sam Houston , TX , USA
| | - Prajeeda Nair
- c Coagulation & Blood Research, US Army Institute of Surgical Research, JBSA Fort , Sam Houston , TX , USA
| | - Andrew P Cap
- a Department of Surgery, McGovern Medical School , The University of Texas Health Science Center , Houston , TX , USA.,c Coagulation & Blood Research, US Army Institute of Surgical Research, JBSA Fort , Sam Houston , TX , USA
| | - Charles E Wade
- a Department of Surgery, McGovern Medical School , The University of Texas Health Science Center , Houston , TX , USA
| | - Charles S Cox
- b Department of Pediatric Surgery, McGovern Medical School , The University of Texas Health Science Center , Houston , TX , USA
| | - Brijesh S Gill
- a Department of Surgery, McGovern Medical School , The University of Texas Health Science Center , Houston , TX , USA
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Buprenorphine Analgesia Leads to Coagulopathy and Increased Plasma Fibrinogen in Healthy Rats: Implications For Small Animal Research. Shock 2018; 48:78-84. [PMID: 27984521 DOI: 10.1097/shk.0000000000000821] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Buprenorphine is the recommended analgesic for post-surgical pain and associated stress in small animal research. Our aim was to examine the effect of isoflurane anesthesia and buprenorphine analgesia on blood coagulation in the rat using rotational thromboelastometry. METHODS Adult male Sprague Dawley rats were randomly assigned to one of four groups (n = 6): baseline (Thiobarb anesthesia), 5% isoflurane anesthesia, isoflurane-buprenorphine (0.05-mg/kg s.c.), and buprenorphine alone. After 1 h, animals were anesthetized and blood was sampled. RESULTS We report that isoflurane or buprenorphine had little or no effects on clotting times, clot formation, or clot lysis in EXTEM or INTEM. However, buprenorphine significantly increased FIBTEM alpha-angle, clot formation rates, and maximum clot formation velocities. Buprenorphine also increased EXTEM, FIBTEM, and INTEM A10 (clot strength), maximum clot firmness (clot quality), and maximum clot elasticity ( (clot elasticity). The combination of isoflurane and buprenorphine significantly increased clot amplitude but not to the same extent. The fibrinogen contribution to clot strength was 1.9-fold higher than baseline in the buprenorphine group, and 1.4-fold higher in the isoflurane-buprenorphine group. Plasma fibrinogen levels were 2.5-fold higher in both groups compared with the baseline value or isoflurane group (6.1 g/L vs. 2.4 g/L, P < 0.05). CONCLUSIONS We conclude buprenorphine analgesia significantly increased clot strength without affecting fibrinolysis, and increased plasma fibrinogen, implying that the drug increased liver fibrinogen synthesis and release. Possible implications for small animal research are discussed.
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Botto A, Bruno B, Maurella C, Riondato F, Tarducci A, Mengozzi G, Borrelli A. Thromboelastometric assessment of hemostasis following hydroxyethyl starch (130/0.4) administration as a constant rate infusion in hypoalbuminemic dogs. BMC Vet Res 2018; 14:33. [PMID: 29386022 PMCID: PMC5793362 DOI: 10.1186/s12917-018-1357-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 01/17/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The primary aim was to evaluate by means of thromboelastometry (ROTEM) the effects of hydroxyethyl starch (HES) 130/0.4 administered as a constant rate infusion (CRI) on hemostasis in hypoalbuminemic dogs. The second aim was to use ROTEM analysis to detect whether all hypoalbuminemic dogs of our population were hypercoagulable. RESULTS The study sample was 20 hypoalbuminemic dogs (albumin < 2 g/dl) with normal perfusion parameters and requiring intravenous fluid therapy. In order to support plasma colloid osmotic pressure, in addition to crystalloid, HES 130/0.4 was administered as a constant rate infusion at 1 ml/kg/h (group 1, n = 11) or 2 ml/kg/h for 24 h (group 2, n = 9). Blood samples were collected at baseline (T0) and 24 h postinfusion (T1); coagulation was assessed by standard coagulation profile (prothrombin time, activated partial thromboplastin time, and fibrinogen), and ROTEM analysis (in-TEM®, ex-TEM® and fib- TEM® profile). No statistically significant differences in ROTEM values in group 1 were observed (P > 0.05), whereas in group 2 statistically significant differences (P < 0.05) were found at T1 in the in-TEM® profile [decrease in clot formation time (P = 0.04) and increase in α angle (P = 0.02)] and in the ex-TEM® profile [increase in maximum clot firmness (P = 0.008) and α angle (P = 0.01)]; no changes were identified in the fib-TEM® profile. In both groups, a statistically significant decrease (P = 0.007) in hematocrit was noted, whereas no statistically significant differences in platelet count and standard coagulation profile were found. In group 2, a statistically significant increase in TS values (P = 0.03) was noted at T1. ROTEM tracings indicating a hypercoagulable state were observed in 7/20 dogs at T0 (5/11 in group 1 and 2/9 in the group 2). CONCLUSION Our findings suggest that HES 130/0.4 administered as CRI does not cause hypocoagulability in hypoalbuminemic dogs. A trend toward hypercoagulability, probably related to the underlying diseases, was observed in group 2 at T1. Although all dogs were hyoalbuminemic, only 7/20 were hypercoagulable at T0, confirming the lack of correlation between albumin level and prothrombotic state.
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Affiliation(s)
- Angelica Botto
- Department of Veterinary Science, University of Turin, Largo Paolo Braccini n°2-5, 10095, Grugliasco, TO, Italy
| | - Barbara Bruno
- Department of Veterinary Science, University of Turin, Largo Paolo Braccini n°2-5, 10095, Grugliasco, TO, Italy
| | - Cristiana Maurella
- Istituto Zooprofilattico Sperimentale del Piemonte, Liguria e Valle d'Aosta, via Bologna 148, 10154, Torino, Italy
| | - Fulvio Riondato
- Department of Veterinary Science, University of Turin, Largo Paolo Braccini n°2-5, 10095, Grugliasco, TO, Italy
| | - Alberto Tarducci
- Department of Veterinary Science, University of Turin, Largo Paolo Braccini n°2-5, 10095, Grugliasco, TO, Italy
| | - Giulio Mengozzi
- Department of Public Health and Pediatric Sciences, C.so Bramante 88/90, 10100, Torino, Italy
| | - Antonio Borrelli
- Department of Veterinary Science, University of Turin, Largo Paolo Braccini n°2-5, 10095, Grugliasco, TO, Italy.
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Ichikawa J, Osada Y, Kodaka M, Nishiyama K, Komori M. Association Between Platelet Count and Postoperative Blood Loss in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass and Fresh Frozen Plasma Administration Guided by Thromboelastometry. Circ J 2018; 82:677-683. [DOI: 10.1253/circj.cj-17-0712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Junko Ichikawa
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Yoshiko Osada
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Mitsuharu Kodaka
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Keiko Nishiyama
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Makiko Komori
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
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Raubenheimer K, Hickey D, Leveritt M, Fassett R, Ortiz de Zevallos Munoz J, Allen JD, Briskey D, Parker TJ, Kerr G, Peake JM, Pecheniuk NM, Neubauer O. Acute Effects of Nitrate-Rich Beetroot Juice on Blood Pressure, Hemostasis and Vascular Inflammation Markers in Healthy Older Adults: A Randomized, Placebo-Controlled Crossover Study. Nutrients 2017; 9:nu9111270. [PMID: 29165355 PMCID: PMC5707742 DOI: 10.3390/nu9111270] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 11/09/2017] [Accepted: 11/12/2017] [Indexed: 12/21/2022] Open
Abstract
Aging is associated with a vasoconstrictive, pro-coagulant, and pro-inflammatory profile of arteries and a decline in the bioavailability of the endothelium-derived molecule nitric oxide. Dietary nitrate elicits vasodilatory, anti-coagulant and anti-inflammatory effects in younger individuals, but little is known about whether these benefits are evident in older adults. We investigated the effects of 140 mL of nitrate-rich (HI-NI; containing 12.9 mmol nitrate) versus nitrate-depleted beetroot juice (LO-NI; containing ≤0.04 mmol nitrate) on blood pressure, blood coagulation, vascular inflammation markers, plasma nitrate and nitrite before, and 3 h and 6 h after ingestion in healthy older adults (five males, seven females, mean age: 64 years, age range: 57-71 years) in a randomized, placebo-controlled, crossover study. Plasma nitrate and nitrite increased 3 and 6 h after HI-NI ingestion (p < 0.05). Systolic, diastolic and mean arterial blood pressure decreased 3 h relative to baseline after HI-NI ingestion only (p < 0.05). The number of blood monocyte-platelet aggregates decreased 3 h after HI-NI intake (p < 0.05), indicating reduced platelet activation. The number of blood CD11b-expressing granulocytes decreased 3 h following HI-NI beetroot juice intake (p < 0.05), suggesting a shift toward an anti-adhesive granulocyte phenotype. Numbers of blood CD14++CD16⁺ intermediate monocyte subtypes slightly increased 6 h after HI-NI beetroot juice ingestion (p < 0.05), but the clinical implications of this response are currently unclear. These findings provide new evidence for the acute effects of nitrate-rich beetroot juice on circulating immune cells and platelets. Further long-term research is warranted to determine if these effects reduce the risk of developing hypertension and vascular inflammation with aging.
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Affiliation(s)
- Kyle Raubenheimer
- Tissue Repair and Translational Physiology Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, OLD 4059, Australia.
- School of Biomedical Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, OLD 4059, Australia.
| | - Danica Hickey
- Tissue Repair and Translational Physiology Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, OLD 4059, Australia.
| | - Michael Leveritt
- School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, OLD 4059, Australia.
| | - Robert Fassett
- School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, OLD 4059, Australia.
| | | | - Jason D Allen
- Institute of Sport Exercise and Active Living, Victoria University, Melbourne, VIC 8001, Australia.
| | - David Briskey
- School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, OLD 4059, Australia.
| | - Tony J Parker
- Tissue Repair and Translational Physiology Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, OLD 4059, Australia.
- School of Biomedical Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, OLD 4059, Australia.
| | - Graham Kerr
- School of Exercise and Nutrition Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, OLD 4059, Australia.
| | - Jonathan M Peake
- Tissue Repair and Translational Physiology Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, OLD 4059, Australia.
- School of Biomedical Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, OLD 4059, Australia.
| | - Natalie M Pecheniuk
- School of Biomedical Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, OLD 4059, Australia.
| | - Oliver Neubauer
- Tissue Repair and Translational Physiology Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, OLD 4059, Australia.
- School of Biomedical Sciences, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, OLD 4059, Australia.
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81
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Holck MH, Christensen TD, Hvas AM. Influence of selected antithrombotic treatment on thromboelastometric results. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 78:11-17. [DOI: 10.1080/00365513.2017.1403038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Mia Hammer Holck
- Department of Clinical Biochemistry, Centre of Haemophilia and Thrombosis, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Thomas Decker Christensen
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Centre of Haemophilia and Thrombosis, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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82
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Blaine KP, Sakai T. Viscoelastic Monitoring to Guide Hemostatic Resuscitation in Liver Transplantation Surgery. Semin Cardiothorac Vasc Anesth 2017; 22:150-163. [PMID: 29099334 DOI: 10.1177/1089253217739121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Coagulopathic bleeding must be anticipated during liver transplantation (LT) surgery. Patients with end-stage liver disease (ESLD) often present with disease-related hematologic disturbances, including the loss of hepatic procoagulant and anticoagulant clotting factors and thrombocytopenia. Transplantation surgery itself presents additional hemostatic changes, including hyperfibrinolysis. Viscoelastic monitoring (VEM) is often used to provide targeted, personalized hemostatic therapies for complex bleeding states including cardiac surgery and major trauma. The use in these coagulopathic conditions led to its application to LT, although the mechanisms of coagulopathy in these patients are quite different. While VEM is often used during transplant surgeries in Europe and North America, evidence supporting its use is limited to a few small clinical studies. The theoretical and clinical applications of the standard and specialized VEM assays are discussed in the setting of LT and ESLD.
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Affiliation(s)
- Kevin P Blaine
- 1 Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Tetsuro Sakai
- 2 University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
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83
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Walsh M, Fritz S, Hake D, Son M, Greve S, Jbara M, Chitta S, Fritz B, Miller A, Bader MK, McCollester J, Binz S, Liew-Spilger A, Thomas S, Crepinsek A, Shariff F, Ploplis V, Castellino FJ. Targeted Thromboelastographic (TEG) Blood Component and Pharmacologic Hemostatic Therapy in Traumatic and Acquired Coagulopathy. Curr Drug Targets 2017; 17:954-70. [PMID: 26960340 PMCID: PMC5374842 DOI: 10.2174/1389450117666160310153211] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 10/13/2015] [Accepted: 12/15/2015] [Indexed: 12/17/2022]
Abstract
Trauma-induced coagulopathy (TIC) is a recently described condition which traditionally has been diagnosed by the common coagulation tests (CCTs) such as prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), platelet count, and fibrinogen levels. The varying sensitivity and specificity of these CCTs have led trauma coagulation researchers and clinicians to use Viscoelastic Tests (VET) such as Thromboelastography (TEG) to provide Targeted Thromboelastographic Hemostatic and Adjunctive Therapy (TTHAT) in a goal directed fashion to those trauma patients in need of hemostatic resuscitation. This review describes the utility of VETs, in particular, TEG, to provide TTHAT in trauma and acquired non-trauma-induced coagulopathy.
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Affiliation(s)
- Mark Walsh
- Memorial Hospital of South Bend, South Bend, Indiana 46601, USA.
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84
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Ranucci M, Baryshnikova E, Pistuddi V, Menicanti L, Frigiola A. The effectiveness of 10 years of interventions to control postoperative bleeding in adult cardiac surgery. Interact Cardiovasc Thorac Surg 2017; 24:196-202. [PMID: 27756812 DOI: 10.1093/icvts/ivw339] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/05/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives Postoperative bleeding in cardiac surgery remains an important complication, leading to increased morbidity and mortality. Different interventions are possible to prevent/treat postoperative bleeding. The present study aims to investigate the effectiveness of these interventions in a real-world scenario. Methods This is a retrospective study based on 19 670 consecutive adult cardiac surgery patients operated from 2000 to 2015. During the study period, the following interventions have been applied and tested for effectiveness with a before versus after analysis: thromboelastography (TEG)-based diagnosis and treatment in actively bleeding patients; platelet function tests (PFTs); timing of surgery based on PFTs; fresh frozen plasma (FFP)-free strategy using prothrombin complex concentrate and fibrinogen concentrate. Results TEG-based diagnostic and therapeutic approach resulted in a significant (P = 0.006) reduction of postoperative bleeding and significant (P = 0.001) increase in platelet concentrate transfusion rate. Timing of surgery based on PFTs resulted in a significant reduction of postoperative bleeding (P = 0.001), surgical re-exploration rate (P = 0.002), FFP (P = 0.001) and platelet concentrate (P = 0.016) transfusion rate. FFP-free strategy was associated with a significant decrease in postoperative bleeding (P = 0.005) and FFP transfusions (P = 0.001). The combination of all the interventions was associated with a significant (P = 0.001) reduction in postoperative bleeding, surgical re-exploration rate and FFP transfusions, whereas platelet concentrate transfusion rate was significantly (P = 0.001) higher. Conclusions Despite a continuous increase in the bleeding risk profile, the application of a bundle of interventions is effective in controlling postoperative bleeding and related complications. Platelet transfusions remain unreplaceable in the present scenario.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, Milan, Italy
| | - Ekaterina Baryshnikova
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, Milan, Italy
| | - Valeria Pistuddi
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, Milan, Italy
| | - Lorenzo Menicanti
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
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85
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Tshikudi DM, Tripathi MM, Hajjarian Z, Van Cott EM, Nadkarni SK. Optical sensing of anticoagulation status: Towards point-of-care coagulation testing. PLoS One 2017; 12:e0182491. [PMID: 28771571 PMCID: PMC5542647 DOI: 10.1371/journal.pone.0182491] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 07/19/2017] [Indexed: 11/18/2022] Open
Abstract
Anticoagulant overdose is associated with major bleeding complications. Rapid coagulation sensing may ensure safe and accurate anticoagulant dosing and reduce bleeding risk. Here, we report the novel use of Laser Speckle Rheology (LSR) for measuring anticoagulation and haemodilution status in whole blood. In the LSR approach, blood from 12 patients and 4 swine was placed in disposable cartridges and time-varying intensity fluctuations of laser speckle patterns were measured to quantify the viscoelastic modulus during clotting. Coagulation parameters, mainly clotting time, clot progression rate (α-angle) and maximum clot stiffness (MA) were derived from the clot viscoelasticity trace and compared with standard Thromboelastography (TEG). To demonstrate the capability for anticoagulation sensing in patients, blood samples from 12 patients treated with warfarin anticoagulant were analyzed. LSR clotting time correlated with prothrombin and activated partial thromboplastin time (r = 0.57-0.77, p<0.04) and all LSR parameters demonstrated good correlation with TEG (r = 0.61-0.87, p<0.04). To further evaluate the dose-dependent sensitivity of LSR parameters, swine blood was spiked with varying concentrations of heparin, argatroban and rivaroxaban or serially diluted with saline. We observed that anticoagulant treatments prolonged LSR clotting time in a dose-dependent manner that correlated closely with TEG (r = 0.99, p<0.01). LSR angle was unaltered by anticoagulation whereas TEG angle presented dose-dependent diminution likely linked to the mechanical manipulation of the clot. In both LSR and TEG, MA was largely unaffected by anticoagulation, and LSR presented a higher sensitivity to increased haemodilution in comparison to TEG (p<0.01). Our results establish that LSR rapidly and accurately measures the response of various anticoagulants, opening the opportunity for routine anticoagulation monitoring at the point-of-care or for patient self-testing.
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Affiliation(s)
- Diane M. Tshikudi
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Markandey M. Tripathi
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Zeinab Hajjarian
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Elizabeth M. Van Cott
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Seemantini K. Nadkarni
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
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86
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A Novel Device for the Evaluation of Hemostatic Function in Critical Care Settings. Anesth Analg 2017; 123:1372-1379. [PMID: 27224934 DOI: 10.1213/ane.0000000000001413] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Major surgical procedures often result in significant intra- and postoperative bleeding. The ability to identify the cause of the bleeding has the potential to reduce the transfusion of blood products and improve patient care. We present a novel device, the Quantra Hemostasis Analyzer, which has been designed for automated, rapid, near-patient monitoring of hemostasis. The Quantra is based on Sonic Estimation of Elasticity via Resonance Sonorheometry, a proprietary technology that uses ultrasound to measure clot time and clot stiffness from changes in viscoelastic properties of whole blood during coagulation. We present results of internal validation and analytical performance testing of the technology and demonstrate the ability to characterize the key functional components of hemostasis.
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87
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Endothelial Cell-derived Extracellular Vesicles Size-dependently Exert Procoagulant Activity Detected by Thromboelastometry. Sci Rep 2017. [PMID: 28623360 PMCID: PMC5473891 DOI: 10.1038/s41598-017-03159-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Endothelial cells (ECs) are major modulators of hemostasis by expressing and releasing pro- and anticoagulant mediators into the circulation. Previous studies showed that cultured ECs release procoagulant mediators into cell culture supernatants as evidenced by the reduction of viscoelastic clotting time. This effect was reversed with an anti-tissue factor antibody. Here, we aimed to investigate whether tissue factor (TF) was released by endothelial-derived extracellular vesicles (EVs) and which portion of the released vesicles displays the most prominent procoagulant properties. After stimulation of ECs with tumor-necrosis factor-α (TNF-α) the supernatants of EC cultures were subjected to differential centrifugation steps to collect larger and smaller EVs which were then characterised by nanoparticle tracking analysis (NTA) and flow cytometry. Mixed with fresh human blood and analysed by thromboelastometry EVs exerted a significant procoagulant stimulus, which could be partly reversed by addition of an anti-TF antibody. Moreover, TF activity was confirmed in the centrifuged fractions. In summary, our results provide evidence of the procoagulant potential of smaller and larger endothelial-derived EV fractions detected by thromboelastometry. The observed effect is most likely due to the release of TF-bearing EVs of different dimensions, which are released upon TNF-α stimulation of endothelial cell cultures.
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88
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Haemotherapy algorithm for the management of trauma-induced coagulopathy: an Australian perspective. Curr Opin Anaesthesiol 2017; 30:265-276. [PMID: 28151829 DOI: 10.1097/aco.0000000000000447] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Recent advances in the understanding of the pathophysiological processes associated with traumatic haemorrhage and trauma-induced coagulopathy have resulted in improved outcomes for seriously injured trauma patients. However, a significant number of trauma patients still die from haemorrhage. This article reviews the various transfusion strategies utilized in the management of traumatic haemorrhage and describes the major haemorrhage protocol (MHP) strategy employed by an Australian trauma centre. RECENT FINDINGS Few topics in trauma resuscitation incite as much debate and controversy as to what constitutes the 'ideal' MHP. There is a widespread geographical and institutional variation in clinical practice. Three strategies are commonly utilized; fixed ratio major haemorrhage protocol (FRMHP), viscoelastic haemostatic assay (VHA)-guided MHP and hybrid MHP. The majority of trauma centres utilize an FRMHP and there is high-level evidence to support the use of high blood product ratios. It can be argued that the FRMHP is too simplistic to be applied to all trauma patients and that the use of VHA-guided MHP with predominant factor concentrate transfusion can allow rapid individualized interventions. In between these two strategies is a hybrid MHP, combining early FRMHP with subsequent VHA-guided transfusion. SUMMARY There are advantages and disadvantages to each of the various MHP strategies and the evidence base to support one above another with any certainty is lacking at this time. One strategy cannot be considered superior to the other and the choice of MHP is dependent on interpretation of the current literature and local institutional logistical considerations. A number of exciting studies are currently underway that will certainly increase the evidence base and help inform clinical practice.
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89
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Sharma R, Letson HL, Smith S, Dobson GP. Tranexamic acid leads to paradoxical coagulation changes during cardiac surgery: a pilot rotational thromboelastometry study. J Surg Res 2017; 217:100-112. [PMID: 28602219 DOI: 10.1016/j.jss.2017.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/19/2017] [Accepted: 05/01/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is increasingly used during major surgery with the goal to reduce excessive bleeding, transfusion requirements, and reexploration. Our aim was to examine the effect of TXA on coagulation at different times during cardiac surgery using rotational thromboelastometry. MATERIALS AND METHODS Nineteen adult males (EuroSCORE 4-5) were recruited consecutively for first-time cardiopulmonary bypass (CPB) surgery. Ten patients received TXA at anesthesia and nine received no TXA. Rotational thromboelastometry analysis occurred before anesthesia (baseline), after sternotomy, after CPB-heparinization and surgery, and after protamine administration-sternal closure. RESULTS A median sternotomy had no effect on clot time (CT), formation, amplitude, or lysis in non-TXA patients. In contrast, TXA patients had twofold prolonged clotting time (all-tests) and ∼30% reduced FIBTEM (A5-30) and maximum clot firmness, indicating reduced thrombin generation and lower clot fibrinogen. After CPB, CTs in both groups were prolonged, possibly linked to overheparinization. In addition, TXA patients had significantly decreased EXTEM (A5-30), suggesting lower clot strength. After protamine-sternal closure, clotting time remained prolonged in both groups, and TXA patients had a persistently 25%-33% lower FIBTEM (A5-30) and maximum clot firmness. TXA patients also had significantly reduced platelet numbers (37% from baseline), which continued Days 1 and 2. Maximum clot lysis was <10% indicating little or no hyperfibrinolysis during cardiac surgery. CONCLUSIONS In this nonrandomized, nonblinded, observational trial, patients in the TXA group displayed prolonged CTs and clot fibrinogen (FIBTEM A5-30) after sternotomy, decreased clot strength (EXTEM) after CPB/surgery, and acute thrombocytopenia after protamine-sternal closure. There was no significant decrease in clot lysis, questioning the need for TXA in this medium-risk group.
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Affiliation(s)
- Rajiv Sharma
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, Australia
| | - Hayley L Letson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, Australia
| | - Samuel Smith
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, Australia
| | - Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, Australia.
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90
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Budnik I, Shenkman B, Hauschner H, Zilinsky I, Savion N. Role of heterotrimeric G proteins in platelet activation and clot formation in platelets treated with integrin αIIbβ3 inhibitor. Platelets 2017; 29:265-269. [DOI: 10.1080/09537104.2017.1295136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Ivan Budnik
- Department of Pathophysiology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Boris Shenkman
- National Hemophilia Center, Sheba Medical Center, Tel-Hashomer, Israel
| | - Hagit Hauschner
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Isaac Zilinsky
- Department of Plastic Surgery, Sheba Medical Center, Tel-Hashomer and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Naphtali Savion
- Goldschleger Eye Research Institute, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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91
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Hernandez Conte A, Perotti D, Farac L. Thromboelastrography (TEG) Is Still Relevant in the 21st Century as a Point-of-Care Test for Monitoring Coagulation Status in the Cardiac Surgical Suite. Semin Cardiothorac Vasc Anesth 2017; 21:212-216. [DOI: 10.1177/1089253217699282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since their introduction into clinical practice in the early 1960s, viscoelastic point-of-care (POC) testing—thromboelastrography (TEG) and thromboelastrometry (ROTEM)—has become increasingly popular in intensive care units, operating rooms, and emergency room settings. As TEG has been an established POC viscoelastic testing modality for many years, there has been more research and analysis of its utility and ability to reduce transfusions in the general, cardiac, and liver surgical sectors compared with ROTEM. The role of TEG versus ROTEM has been greatly disputed, although both continue to be utilized in the cardiac suite to guide transfusion in cardiac surgery as these procedures produce a profoundly different form of bleeding compared to other surgical interventions.
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Affiliation(s)
| | | | - Lauren Farac
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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92
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Biolik G, Kokot M, Sznapka M, Święszek A, Ziaja D, Pawlicki K, Ziaja K. Platelet reactivity in thromboelastometry. Revision of the FIBTEM test: a basic study. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:216-222. [PMID: 28276730 DOI: 10.1080/00365513.2017.1292538] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This study aimed to investigate modifications to the FIBTEM test to better assess fibrinogen levels and the quality of fibrin polymerization in citrated blood using Multiplate impedance aggregometry to verify platelet inhibition. Blood samples from 26 healthy volunteers were subjected to thromboelastometry studies (EXTEM/FIBTEM tests) in accordance with the standard study protocol (cytochalasin D) and according to a modified protocol (synthetic IIbIIIa receptor antagonist vs. acetylsalicylic acid [ASA] + synthetic IIbIIIa receptor antagonist instead of cytochalasin D). Independent of thromboelastometry, Multiplate impedance aggregometry was used to assess the degree of restriction by the platelet blocked with the following treatments: (1) cytochalasin D, (2) synthetic IIbIIIa antagonist or (3) ASA + synthetic IIbIIIa antagonist to assess the aggregation response to activation with an agonist (ADP, collagen, thrombin receptor activating peptide-6 [TRAP-6], and arachidonic acid). Via aggregometry, cytochalasin D more weakly inhibited platelet aggregation than simultaneous administration of the -IIbIIIa receptor antagonist with ASA. However, total platelet aggregation inhibition was observed after simultaneous administration of cytochalasin D combined with a synthetic IIbIIIa receptor antagonist. In the thromboelastometry, a significant decrease of the A10, A20 and MCF parameters were observed in the EXTEM/FIBTEM tests after they were modified by the addition of a synthetic IIbIIIa receptor antagonist alone or in combination with ASA. In conclusion, in this Multiplate- and ROTEM-based laboratory approach, a two-way blockade (IIbIIIa-antagonist + cytochalasine D) was sufficient to completely inhibit procoagulant platelet function as observed by aggregometry and thromboelastometry.
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Affiliation(s)
- Grzegorz Biolik
- a Department of General Vascular Surgery, Faculty of Medicine in Katowice , School of Health Science, Medical University of Silesia , Katowice , Poland
| | - Michał Kokot
- b Department of Internal Medicine and Metabolic Diseases, Faculty of Medicine in Katowice , School of Health Science, Medical University of Silesia , Katowice , Poland
| | - Mariola Sznapka
- a Department of General Vascular Surgery, Faculty of Medicine in Katowice , School of Health Science, Medical University of Silesia , Katowice , Poland
| | - Agnieszka Święszek
- a Department of General Vascular Surgery, Faculty of Medicine in Katowice , School of Health Science, Medical University of Silesia , Katowice , Poland
| | - Damian Ziaja
- c Faculty of Medicine in Katowice , Unit of Physiology, School of Health Care, Medical University of Silesia , Katowice , Poland
| | - Krzysztof Pawlicki
- d Department of Biophysics, Faculty of Medicine in Katowice , School of Health Science Medical University of Silesia , Katowice , Poland
| | - Krzysztof Ziaja
- a Department of General Vascular Surgery, Faculty of Medicine in Katowice , School of Health Science, Medical University of Silesia , Katowice , Poland
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94
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Huffmyer JL, Fernandez LG, Haghighian C, Terkawi AS, Groves DS. Comparison of SEER Sonorheometry With Rotational Thromboelastometry and Laboratory Parameters in Cardiac Surgery. Anesth Analg 2016; 123:1390-1399. [DOI: 10.1213/ane.0000000000001507] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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95
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A Comparison of a New Ultrasound-Based Whole Blood Viscoelastic Test (SEER Sonorheometry) Versus Thromboelastography in Cardiac Surgery. Anesth Analg 2016; 123:1400-1407. [DOI: 10.1213/ane.0000000000001362] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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96
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Naik BI, Durieux ME, Knisely A, Sharma J, Bui-Huynh VC, Yalamuru B, Terkawi AS, Nemergut EC. SEER Sonorheometry Versus Rotational Thromboelastometry in Large Volume Blood Loss Spine Surgery. Anesth Analg 2016; 123:1380-1389. [DOI: 10.1213/ane.0000000000001509] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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97
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Reis SP, DeSimone N, Barnes L, Nordeck SM, Grewal S, Cripps M, Kalva SP. The Utility of Viscoelastic Testing in Patients Undergoing IR Procedures. J Vasc Interv Radiol 2016; 28:78-87. [PMID: 27884687 DOI: 10.1016/j.jvir.2016.09.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 12/19/2022] Open
Abstract
Whole-blood viscoelastic testing can identify patient-specific coagulation disturbances, allowing for targeted repletion of necessary coagulation factors and differentiation between coagulopathy and surgical bleeding that requires intervention. Viscoelastic testing complements standard coagulation tests and has been shown to decrease transfusion requirements and improve survival in bleeding patients. Viscoelastic testing also can be used to predict bleeding and improve the care of patients undergoing interventional radiology (IR) procedures.
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Affiliation(s)
- Stephen P Reis
- Department of Radiology, New York Presbyterian Hospital, New York, New York; Department of Radiology, Division of Interventional Radiology, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY 10032.
| | - Nicole DeSimone
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Laura Barnes
- Department of Radiology, Division of Interventional Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shaun M Nordeck
- University of Texas Southwestern Medical School, Dallas, Texas
| | - Simer Grewal
- University of Texas Southwestern Medical School, Dallas, Texas
| | - Michael Cripps
- Department of Surgery, Division of Burn, Trauma and Critical Care, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sanjeeva P Kalva
- Department of Radiology, Division of Interventional Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
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98
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Hällgren O, Svenmarker S, Appelblad M. Implementing a Statistical Model for Protamine Titration: Effects on Coagulation in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2016; 31:516-521. [PMID: 27712970 DOI: 10.1053/j.jvca.2016.07.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To implement a statistical model for protamine titration. DESIGN Prospective randomized trial. SETTING University hospital. PARTICIPANTS Sixty (n = 30+30) patients scheduled for elective coronary artery bypass surgery were randomly assigned to 2 groups. INTERVENTIONS Protamine dose calculated according to an algorithm established from a statistical model or to a fixed protamine-heparin dose ratio (1:1). MEASUREMENTS AND MAIN RESULTS Both groups demonstrated comparable patient demographics and intraoperative data. Coagulation effects were evaluated using rotational thromboelastometry. Using the statistical model reduced (p<0.01) the protamine dose from 426±43 mg to 251±66 mg, followed by significantly (p<0.01) shorter intrinsic clotting time (208±29 seconds versus 244±52 seconds) and stronger clot firmness (p = 0.01), and effects on indices of extrinsic or fibrinogen coagulation pathways were insignificant. Test of residual heparin was negative in all patients after protamine administration, aligned with insignificant (p = 0.27) intergroup heparinase-verified clotting time differences. CONCLUSIONS The statistical model for protamine titration is clinically feasible and protects the patient from exposure to excessive doses of protamine, with advantageous effects on coagulation as measured using rotational thromboelastometry. Significance regarding clinical outcome is yet to be defined.
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Affiliation(s)
- Oskar Hällgren
- Department of Public Health and Clinical Medicine, Heart Centre, Umeå University, Umeå, Sweden
| | - Staffan Svenmarker
- Department of Public Health and Clinical Medicine, Heart Centre, Umeå University, Umeå, Sweden.
| | - Micael Appelblad
- Department of Public Health and Clinical Medicine, Heart Centre, Umeå University, Umeå, Sweden
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[Rotational thromboelastometry for the diagnosis of coagulation disorders]. Med Klin Intensivmed Notfmed 2016; 113:542-551. [PMID: 27405939 DOI: 10.1007/s00063-016-0194-4] [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: 02/04/2016] [Revised: 04/22/2016] [Accepted: 05/01/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Compared to conventional coagulation assays, as prothrombin time (PT) or activated partial thromboplastin time (aPTT), viscoelastic methods of coagulation analysis, including rotational thromboelastometry (ROTEM®, Tem International GmbH, Munich, Germany), yield prognostic benefits. Results of ROTEM® in citrated whole blood could be generated within 10-12 min and allow for a qualitative and semiquantitative characterisation of clot kinetics. Based on ROTEM® results, the switch between empiric approaches of treating coagulopathy to a goal-directed approach could be accelerated. Introduction of ROTEM® reduces transfusion requirements and the need for single factor concentrates. Thus, ROTEM® reduces transfusion-related adverse events, and additionally implement therapeutic cost effectiveness. OBJECTIVES This review provides a short introduction in the methodology of ROTEM®, showing how the combination of assays with different commercially available ROTEM® reagents allows for rapid differential diagnosis of common coagulopathies in clinical practice. Furthermore, prognostic benefits and limitations of ROTEM® diagnostics are described. Finally, we discuss the potential fields of ROTEM® application in different surgical settings. CONCLUSION ROTEM® appears to be a contemporary, applicable and effective method in diagnosing coagulopathy and for subsequent algorithm-based goal-directed therapy.
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Van Poucke S, Stevens K, Wetzels R, Kicken C, Verhezen P, Theunissen M, Kuiper G, van Oerle R, Henskens Y, Lancé M. Early platelet recovery following cardiac surgery with cardiopulmonary bypass. Platelets 2016; 27:751-757. [PMID: 27164510 DOI: 10.3109/09537104.2016.1173665] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) is frequently associated with low platelet count (PC) and disturbed platelet function (PF). While PC is easy to measure, PF is more difficult to assess. Moreover, the time-related platelet dysfunction and recovery after CPB is not fully elucidated. Platelet dysfunction could lead to bleeding but also to coronary graft failure. Laboratory tests could provide more insights into PF after CABG. The aim of the current study was to investigate the time-related PF induced by CPB. Blood samples of 20 patients with a preoperative PC of more than 250 × 109/L were collected before incision, after weaning from CPB, and 24 h postoperative. Platelet contribution to coagulation was quantified by PLTEM (calculated by means of EXTEM and FIBTEM results). PF was assessed by multiple electrode impedance aggregometry (MEIA) in whole blood and by light transmission aggregometry (LTA) in platelet-rich plasma after stimulation with arachidonic acid (AA), adenosine diphosphate, collagen, and thrombin-receptor-activating peptide. LTA and MEIA analysis demonstrated significant platelet dysfunction after CPB, with partial recovery within 24 h after surgery. AA-induced platelet aggregation increased to higher levels within 24 h after surgery compared to baseline values as measured by LTA. PLTEM maximum clot firmness remained unchanged throughout the study. Correlation analyses revealed that MEIA and rotational thromboelastometry (ROTEM), but not LTA, were dependent on PC and hematocrit. No correlations were found between LTA, MEIA, ROTEM, PC, and clinical outcome parameters. Our results demonstrate a reversible platelet dysfunction recovering within 24 h after CPB. Interestingly, AA-induced platelet aggregation increases to higher levels during the first 24 h postoperatively, which might be important for early initiation of antiplatelet therapy after CABG. MEIA as POC test is able to detect platelet dysfunction during cardiac surgery with a PC of ≥150 × 109/L.
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Affiliation(s)
- Sven Van Poucke
- a Department of Anaesthesiology , Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg (ZOL) , Genk , Belgium
| | - Kris Stevens
- b Department of Anaesthesiology & Pain Treatment , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Rick Wetzels
- c Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Cécile Kicken
- b Department of Anaesthesiology & Pain Treatment , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Paul Verhezen
- c Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Maurice Theunissen
- b Department of Anaesthesiology & Pain Treatment , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Gerhardus Kuiper
- b Department of Anaesthesiology & Pain Treatment , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Rene van Oerle
- c Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Yvonne Henskens
- c Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
| | - Marcus Lancé
- b Department of Anaesthesiology & Pain Treatment , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands.,d Department of Intensive Care , Maastricht University Medical Centre (MUMC+) , Maastricht , The Netherlands
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