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Solomon C, Asmis LM, Spahn DR. Is viscoelastic coagulation monitoring with ROTEM or TEG validated? Scandinavian Journal of Clinical and Laboratory Investigation 2016; 76:503-7. [PMID: 27354213 PMCID: PMC5152534 DOI: 10.1080/00365513.2016.1200136] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Recent years have seen increasing worldwide interest in the use of viscoelastic coagulation monitoring tests, performed using devices such as ROTEM and TEG. The use of such tests to guide haemostatic therapy may help reduce transfusion of allogeneic blood products in bleeding patients and is supported in European guidelines for managing trauma and severe perioperative bleeding. In addition, viscoelastic tests form the basis of numerous published treatment algorithms. However, some publications have stated that viscoelastic tests are not validated. A specific definition of the term validation is lacking and regulatory requirements of the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) have been fulfilled by ROTEM and TEG assays. Viscoelastic tests have been used in pivotal clinical trials, and they are approved for use in most of the world's countries. Provided that locally approved indications are adhered to, the regulatory framework for clinicians to use viscoelastic tests in routine clinical practice is in place.
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Affiliation(s)
- Cristina Solomon
- a Department of Anesthesiology, Perioperative Care and General Intensive Care , Paracelsus Medical University, Salzburg University Hospital , Salzburg , Austria , Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre , Vienna , Austria, and CSL Behring , Marburg , Germany
| | - Lars M Asmis
- b Coagulation Lab and Centre for Perioperative Thrombosis and Hemostasis , Unilabs , Zurich , Switzerland
| | - Donat R Spahn
- c Institute of Anesthesiology, University and University Hospital of Zurich , Zurich , Switzerland
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152
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Nogami K. The utility of thromboelastography in inherited and acquired bleeding disorders. Br J Haematol 2016; 174:503-14. [PMID: 27264484 DOI: 10.1111/bjh.14148] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/30/2016] [Indexed: 01/08/2023]
Abstract
Thromboelastography (TEG) was first described by Hartert in 1948, and was designed to monitor viscoelastic clot strength in whole blood in real time. The current TEG method and Rotational Thromboelastometry (ROTEM) were subsequently developed from the original principles. Both of the modern methods provide data by measuring changes in the viscoelastic strength of a small sample of clotting blood in response to a constant rotational force. The important advantage of these techniques is to visually observe and quantify blood coagulation including the propagation, stabilization and dissolution phases of clot formation under low shear conditions. Analysis of the results provides detailed kinetic data on fibrin generation, clot strength and fibrinolysis. These TEG/ROTEM analyses therefore enable evaluation of global clotting function and the monitoring of haemostatic treatment in various clinical situations, not only in patients with genetic bleeding disorders, such as haemophilia, but also in patients undergoing cardiac surgery, liver transplantation or suffering from traumatic injury. Some evidence suggests that haemostatic management using TEG/ROTEM leads to a reduction in total transfusions of whole blood or clotting factors. Wider clinical application of this technology seems likely.
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Affiliation(s)
- Keiji Nogami
- Department of Paediatrics, Nara Medical University, Kashihara, Nara, Japan
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153
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Abstract
OBJECTIVES An elevated maximal amplitude (mA) value with rapid thrombelastography on admission can identify general trauma patients with an increased risk of venous thromboembolic events (VTEs). We hypothesized that (1) the risk of VTE traditionally assigned to injury lies specifically in those who sustain major orthopaedic trauma and (2) an elevated admission mA value could be used to identify patients with major orthopaedic injuries at risk for VTE during initial hospital admission. DESIGN Retrospective. SETTING University level 1 trauma center. PATIENTS/PARTICIPANTS Consecutive trauma patients admitted to an urban level 1 trauma center between September 2009 and February 2011 who met the criteria for level 1 trauma activation and who were between 18 and 85 years of age were included in our study group. Two groups were created, one whose extremity abbreviated injury severity score was 2 or greater (ORTHO) and the other whose extremity abbreviated injury severity score was <2 (non-ORTHO). MAIN OUTCOME MEASUREMENTS Pulmonary emboli were confirmed by computed tomography angiography, and deep vein thromboses were confirmed by venous duplex. Univariate analyses were conducted and followed by purposeful regression analysis. RESULTS Of note, 1818 patients met the inclusion criteria (310 ORTHO and 1508 non-ORTHO). Despite more hypocoagulable r-TEG values on arrival (alpha angle 71 vs. 73 and mA 62 vs. 64, both P < 0.05), ORTHO patients had higher rates of VTE (6.5% vs. 2.7%, P < 0.001). Stepwise regression generated 4 values to predict development of VTE (age, male gender, white race, and ORTHO). After controlling for these variables, admission mA values ≥65 (odds ratio 3.66) and ≥72 (odds ratio 6.70) were independent predictors of VTEs during hospitalization. CONCLUSIONS Admission rapid thrombelastography mA values can identify patients with major orthopaedic trauma injuries who present with an increased risk of in-hospital deep vein thromboses and pulmonary embolism with a 3.6-fold and 6.7-fold increased risk for mA values ≥65 and ≥72, respectively. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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154
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Prevalence of “Flat-Line” Thromboelastography During Extracorporeal Membrane Oxygenation for Respiratory Failure in Adults. ASAIO J 2016; 62:302-9. [DOI: 10.1097/mat.0000000000000325] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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155
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Whiting P, Al M, Westwood M, Ramos IC, Ryder S, Armstrong N, Misso K, Ross J, Severens J, Kleijnen J. Viscoelastic point-of-care testing to assist with the diagnosis, management and monitoring of haemostasis: a systematic review and cost-effectiveness analysis. Health Technol Assess 2016. [PMID: 26215747 DOI: 10.3310/hta19580] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with substantive bleeding usually require transfusion and/or (re-)operation. Red blood cell (RBC) transfusion is independently associated with a greater risk of infection, morbidity, increased hospital stay and mortality. ROTEM (ROTEM® Delta, TEM International GmbH, Munich, Germany; www.rotem.de), TEG (TEG® 5000 analyser, Haemonetics Corporation, Niles, IL, USA; www.haemonetics.com) and Sonoclot (Sonoclot® coagulation and platelet function analyser, Sienco Inc., Arvada, CO) are point-of-care viscoelastic (VE) devices that use thromboelastometry to test for haemostasis in whole blood. They have a number of proposed advantages over standard laboratory tests (SLTs): they provide a result much quicker, are able to identify what part of the clotting process is disrupted, and provide information on clot formation over time and fibrinolysis. OBJECTIVES This assessment aimed to assess the clinical effectiveness and cost-effectiveness of VE devices to assist with the diagnosis, management and monitoring of haemostasis disorders during and after cardiac surgery, trauma-induced coagulopathy and post-partum haemorrhage (PPH). METHODS Sixteen databases were searched to December 2013: MEDLINE (OvidSP), MEDLINE In-Process and Other Non-Indexed Citations and Daily Update (OvidSP), EMBASE (OvidSP), BIOSIS Previews (Web of Knowledge), Science Citation Index (SCI) (Web of Science), Conference Proceedings Citation Index (CPCI-S) (Web of Science), Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) database, Latin American and Caribbean Health Sciences Literature (LILACS), International Network of Agencies for Health Technology Assessment (INAHTA), National Institute for Health Research (NIHR) HTA programme, Aggressive Research Intelligence Facility (ARIF), Medion, and the International Prospective Register of Systematic Reviews (PROSPERO). Randomised controlled trials (RCTs) were assessed for quality using the Cochrane Risk of Bias tool. Prediction studies were assessed using QUADAS-2. For RCTs, summary relative risks (RRs) were estimated using random-effects models. Continuous data were summarised narratively. For prediction studies, the odds ratio (OR) was selected as the primary effect estimate. The health-economic analysis considered the costs and quality-adjusted life-years of ROTEM, TEG and Sonoclot compared with SLTs in cardiac surgery and trauma patients. A decision tree was used to take into account short-term complications and longer-term side effects from transfusion. The model assumed a 1-year time horizon. RESULTS Thirty-one studies (39 publications) were included in the clinical effectiveness review. Eleven RCTs (n=1089) assessed VE devices in patients undergoing cardiac surgery; six assessed thromboelastography (TEG) and five assessed ROTEM. There was a significant reduction in RBC transfusion [RR 0.88, 95% confidence interval (CI) 0.80 to 0.96; six studies], platelet transfusion (RR 0.72, 95% CI 0.58 to 0.89; six studies) and fresh frozen plasma to transfusion (RR 0.47, 95% CI 0.35 to 0.65; five studies) in VE testing groups compared with control. There were no significant differences between groups in terms of other blood products transfused. Continuous data on blood product use supported these findings. Clinical outcomes did not differ significantly between groups. There were no apparent differences between ROTEM or TEG; none of the RCTs evaluated Sonoclot. There were no data on the clinical effectiveness of VE devices in trauma patients or women with PPH. VE testing was cost-saving and more effective than SLTs. For the cardiac surgery model, the cost-saving was £43 for ROTEM, £79 for TEG and £132 for Sonoclot. For the trauma population, the cost-savings owing to VE testing were more substantial, amounting to per-patient savings of £688 for ROTEM compared with SLTs, £721 for TEG, and £818 for Sonoclot. This finding was entirely dependent on material costs, which are slightly higher for ROTEM. VE testing remained cost-saving following various scenario analyses. CONCLUSIONS VE testing is cost-saving and more effective than SLTs, in both patients undergoing cardiac surgery and trauma patients. However, there were no data on the clinical effectiveness of Sonoclot or of VE devices in trauma patients. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005623. FUNDING The NIHR Health Technology Assessment programme.
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Affiliation(s)
| | - Maiwenn Al
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | - Isaac Corro Ramos
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | | | - Kate Misso
- Kleijnen Systematic Reviews Ltd, York, UK
| | | | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands
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156
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Hans GA, Besser MW. The place of viscoelastic testing in clinical practice. Br J Haematol 2016; 173:37-48. [DOI: 10.1111/bjh.13930] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Gregory A. Hans
- Department of Anaesthesia and Intensive Care Medicine; CHU of Liege; Liege Belgium
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157
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158
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Bae JM. Point of Care: Assessment of Coagulopathy in Hemorrhagic Shock. JOURNAL OF ACUTE CARE SURGERY 2015. [DOI: 10.17479/jacs.2015.5.2.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Jung-Min Bae
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
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159
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Chitlur M, Young G. Global assays in hemophilia. Semin Hematol 2015; 53:40-5. [PMID: 26805906 DOI: 10.1053/j.seminhematol.2015.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2004] [Revised: 11/05/2004] [Accepted: 12/01/2005] [Indexed: 11/11/2022]
Abstract
The quest for the ideal method to study hemostasis in the evaluation and management of patients with bleeding disorders such as hemophilia is an ongoing effort. With the rapid evolution of biotechnology and the emergence of several new products for treatment of patients with hemophilia with and without inhibitors, there is a great need for tests that can be used to reliably evaluate and monitor our interventions. Global assays in coagulation allow the study of the interaction between the components involved in the process of hemostasis and are therefore considered by many to be more reflective of the in vivo hemostatic mechanism. Here we provide a brief review of the most widely used global assays in hemostasis (thrombin generation and thromboelastography) and their utility in the evaluation and management of hemophilia.
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Affiliation(s)
- Meera Chitlur
- Carman and Ann Adams Department of Pediatrics, Division of Hematology/Oncology, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA.
| | - Guy Young
- Department of Pediatrics, Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, CA, USA
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160
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Solomon C, Schöchl H, Ranucci M, Schlimp CJ. Can the Viscoelastic Parameter α-Angle Distinguish Fibrinogen from Platelet Deficiency and Guide Fibrinogen Supplementation? Anesth Analg 2015. [PMID: 26197367 DOI: 10.1213/ane.0000000000000738] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Viscoelastic tests such as thrombelastography (TEG, Haemoscope Inc., Niles, IL) and thromboelastometry (ROTEM, Tem International GmbH, Munich, Germany), performed in whole blood, are increasingly used at the point-of-care to characterize coagulopathic states and guide hemostatic therapy. An algorithm, based on a mono-analysis (kaolin-activated assay) approach, was proposed in the TEG patent (issued in 2004) where the α-angle and the maximum amplitude parameters are used to guide fibrinogen supplementation and platelet administration, respectively. Although multiple assays for both the TEG and ROTEM devices are now available, algorithms based on TEG mono-analysis are still used in many institutions. In light of more recent findings, we discuss here the limitations and inaccuracies of the mono-analysis approach. Research shows that both α-angle and maximum amplitude parameters reflect the combined contribution of fibrinogen and platelets to clot strength. Therefore, although TEG mono-analysis is useful for identifying a coagulopathic state, it cannot be used to discriminate between fibrin/fibrinogen and/or platelet deficits, respectively. Conversely, the use of viscoelastic methods where 2 assays can be run simultaneously, one with platelet inhibitors and one without, can effectively allow for the identification of specific coagulopathic states, such as insufficient fibrin formation or an insufficient contribution of platelets to clot strength. Such information is critical for making the appropriate choice of hemostatic therapy.
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Affiliation(s)
- Cristina Solomon
- From the *CSL Behring, Marburg, Germany; †Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; ‡Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; §Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Salzburg, Austria; and ∥Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Klagenfurt, Klagenfurt, Austria
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161
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Solomon C, Ranucci M, Hochleitner G, Schöchl H, Schlimp CJ. Assessing the Methodology for Calculating Platelet Contribution to Clot Strength (Platelet Component) in Thromboelastometry and Thrombelastography. Anesth Analg 2015; 121:868-878. [PMID: 26378699 PMCID: PMC4568902 DOI: 10.1213/ane.0000000000000859] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2015] [Indexed: 12/28/2022]
Abstract
The viscoelastic properties of blood clot have been studied most commonly using thrombelastography (TEG) and thromboelastometry (ROTEM). ROTEM-based bleeding treatment algorithms recommend administering platelets to patients with low EXTEM clot strength (e.g., clot amplitude at 10 minutes [A10] <40 mm) once clot strength of the ROTEM® fibrin-based test (FIBTEM) is corrected. Algorithms based on TEG typically use a low value of maximum amplitude (e.g., <50 mm) as a trigger for administering platelets. However, this parameter reflects the contributions of various blood components to the clot, including platelets and fibrin/fibrinogen. The platelet component of clot strength may provide a more sensitive indication of platelet deficiency than clot amplitude from a whole blood TEG or ROTEM® assay. The platelet component of the formed clot is derived from the results of TEG/ROTEM® tests performed with and without platelet inhibition. In this article, we review the basis for why this calculation should be based on clot elasticity (e.g., the E parameter with TEG and the CE parameter with ROTEM®) as opposed to clot amplitude (e.g., the A parameter with TEG or ROTEM®). This is because clot elasticity, unlike clot amplitude, reflects the force with which the blood clot resists rotation within the device, and the relationship between clot amplitude (variable X) and clot elasticity (variable Y) is nonlinear. A specific increment of X (ΔX) will be associated with different increments of Y (ΔY), depending on the initial value of X. When calculated correctly, using clot elasticity data, the platelet component of the clot can provide a valuable insight into platelet deficiency in emergency bleeding.
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Affiliation(s)
- Cristina Solomon
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Marco Ranucci
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Gerald Hochleitner
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Herbert Schöchl
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Christoph J. Schlimp
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
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162
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2014 Consensus conference on viscoelastic test-based transfusion guidelines for early trauma resuscitation: Report of the panel. J Trauma Acute Care Surg 2015; 78:1220-9. [PMID: 26151526 DOI: 10.1097/ta.0000000000000657] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
There has been an increased interest in the use of viscoelastic testing to guide blood product replacement during the acute resuscitation of the injured patient. Currently, no uniformly accepted guidelines exist for how this technology should be integrated into clinical care. In September 2014, an international multidisciplinary group of leaders in the field of trauma coagulopathy and resuscitation was assembled for a 2-day consensus conference in Philadelphia, Pennsylvania. This panel included trauma surgeons, hematologists, blood bank specialists, anesthesiologists, and the lay public.Nine questions regarding the impact of viscoelastic testing in the early resuscitation of trauma patients were developed before the conference by panel consensus. Early use was defined as baseline viscoelastic test result thresholds obtained within the first minutes of hospital arrival-when conventional laboratory results are not available. The available data for each question were then reviewed in person using standardized presentations by the expert panel. A consensus summary document was then developed and reviewed by the panel in an open forum. Finally, a two-round Delphi poll was administered to the panel of experts regarding viscoelastic thresholds for triggering the initiation of specific treatments including fibrinogen, platelets, plasma, and prothrombin complex concentrates. This report summarizes the findings and recommendations of this consensus conference.
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163
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Benes J, Zatloukal J, Kletecka J. Viscoelastic Methods of Blood Clotting Assessment - A Multidisciplinary Review. Front Med (Lausanne) 2015; 2:62. [PMID: 26442265 PMCID: PMC4568412 DOI: 10.3389/fmed.2015.00062] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 08/17/2015] [Indexed: 12/12/2022] Open
Abstract
Viscoelastic methods (VEM) made available the bedside assessment of blood clotting. Unlike standard laboratory tests, the results are based on the whole blood coagulation and are available in real time at a much faster turnaround time. In combination with our new knowledge about pathophysiology of the trauma-induced coagulopathy, the goal-oriented treatment protocols have been recently proposed for the initial management of bleeding in trauma victims. Additionally, the utility of viscoelastic monitoring devices has been proved even outside this setting in cardiosurgical patients or those undergoing liver transplantation. Many other situations were described in literature showing the potential use of bedside analysis of coagulation for the management of bleeding or critically ill patients. In the near future, we may expect further improvement in current bedside diagnostic tools enabling not only the assessment of secondary hemostasis but also the platelet aggregation. More sensitive assays for new anticoagulants are underway. Aim of this review is to offer the reader a multidisciplinary overview of VEM and their potential use in anesthesiology and critical care.
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Affiliation(s)
- Jan Benes
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and Teaching Hospital in Plzen, Charles University in Prague , Plzen , Czech Republic ; Faculty of Medicine in Plzen, Biomedical Centre, Charles University in Prague , Plzen , Czech Republic
| | - Jan Zatloukal
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and Teaching Hospital in Plzen, Charles University in Prague , Plzen , Czech Republic
| | - Jakub Kletecka
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and Teaching Hospital in Plzen, Charles University in Prague , Plzen , Czech Republic
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164
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Erber M, Lee G. Cryopellets based on amorphous organic calcium salts: Production, characterization and their usage in coagulation diagnostics. POWDER TECHNOL 2015. [DOI: 10.1016/j.powtec.2015.04.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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165
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The utility of thromboelastometry in prophylactic platelet transfusion for hematological malignancies. Transfus Apher Sci 2015; 53:64-8. [DOI: 10.1016/j.transci.2015.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 02/02/2015] [Accepted: 03/09/2015] [Indexed: 11/21/2022]
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166
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Ortmann E, Rubino A, Altemimi B, Collier T, Besser MW, Klein AA. Validation of viscoelastic coagulation tests during cardiopulmonary bypass. J Thromb Haemost 2015; 13:1207-16. [PMID: 25903995 DOI: 10.1111/jth.12988] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 04/13/2015] [Indexed: 08/31/2023]
Abstract
BACKGROUND Viscoelastic point-of-care tests such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are increasingly used to guide hemostatic therapy after cardiac surgery. The aim of this study was to assess their clinical utility during cardiopulmonary bypass to predict postbypass coagulation status and to guide therapy. METHODS In this prospective study, TEG and ROTEM tests were performed in 52 adult patients undergoing elective cardiac surgery at two time points: near the end of cardiopulmonary bypass and after heparin reversal with protamine. The 95% confidence intervals of the mean difference were compared with a prespecified clinically relevant limit of ± 20% of the value after protamine. RESULTS Both viscoelastic fibrinogen assays were well within the prespecified clinically relevant limit (≥ 79% of patients). The laboratory Clauss fibrinogen was much lower during cardiopulmonary bypass than after protamine (mean difference 1.2 g L(-1) , 95% CI 1.03-1.4, which was outside a clinically acceptable difference. For intrinsically activated tests, clotting times (CT) were different and outside the prespecified limit on TEG (mean difference -1.2 min, 95% CI -1.8 to -0.6) but not on ROTEM (mean difference 2.3 sec, 95% CI -8.6 to 13.2), while clot strength was well within the clinical limit on both devices (≥ 94% of patients). For extrinsically activated tests, clot strength on both TEG and ROTEM was within the pre-specified limit in 98% of patients. CONCLUSIONS Results from TEG and ROTEM tests performed toward the end of cardiopulmonary bypass are similar to results after reversal of heparin. Amplitudes indicating clot strength were the most stable parameters across all tests, whereas CT showed more variability. In contrast, laboratory testing of fibrinogen using the Clauss assay was essentially invalid during cardiopulmonary bypass.
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Affiliation(s)
- E Ortmann
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - A Rubino
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - B Altemimi
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - T Collier
- London School of Hygiene and Tropical Medicine, London, UK
| | - M W Besser
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals Foundation Trust, Cambridge, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
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167
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Application of ROTEM to assess hypercoagulability in patients with lung cancer. Thromb Res 2015; 135:1075-80. [DOI: 10.1016/j.thromres.2015.03.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 02/09/2015] [Accepted: 03/12/2015] [Indexed: 12/21/2022]
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168
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Time impact on non-activated and kaolin-activated blood samples in thromboelastography. BMC Anesthesiol 2015; 15:50. [PMID: 25927487 PMCID: PMC4404121 DOI: 10.1186/s12871-015-0033-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 04/09/2015] [Indexed: 11/15/2022] Open
Abstract
Background The correct methodology of thrombelastography might be influenced by elapsing time. In our study we investigated kaolin activated citrated samples together with non-activated citrated samples in relation to the elapsed times of 0, 15 and 30 minutes to compare both methods and to find out if there is an impact of time on results of thrombelastography. Methods Blood samples obtained from 10 healthy volunteers were analyzed after 0, 15 and 30 minutes from sampling with kaolin activation and without activation. Then the results were analysed and compared between the non-activated and the kaolin-activated method. Results All blood samples became more hypercoagulable with the time elapsing, both in non-activated and kaolin-activated samples and differences between both groups were found statistically and clinically significant after only 0 minutes. Conclusions The non-activated citrated method seems to be reliable and suitable for thrombelastography in non-emergency cases (planned surgical procedures) when we have time to wait 15–30 minutes to get results. In urgent situations a rapid thrombelastography test should be preferred. Although the kaolin-activated method can also be used, results must be interpreted with caution.
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169
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Theusinger OM, Stein P, Levy JH. Point of care and factor concentrate-based coagulation algorithms. Transfus Med Hemother 2015; 42:115-21. [PMID: 26019707 DOI: 10.1159/000381320] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 03/03/2015] [Indexed: 11/19/2022] Open
Abstract
In the last years it has become evident that the use of blood products should be reduced whenever possible. There is increasing evidence regarding serious adverse events, including higher mortality and morbidity, related to transfusions. The use of point of care (POC) devices integrated in algorithms is one of the important mechanisms to limit blood product exposure. Any type of algorithm, especially the POC-based ones, allows goal-directed transfusions of blood products and even better targeted factor concentrate substitutions. Different types of algorithms in different surgical settings (cardiac surgery, trauma, liver surgery etc.) have been established with growing interest in their use as they offer objective therapy for management and reduction of blood product use. The use of POC devices with evidence-based algorithms is important in the bleeding patient independent of its origin (traumatic vs. surgical). The use of factor concentrates compared to the classical blood products can be cost-saving, beneficial for the patient, and in agreement with the WHO-requested standard of care. The empiric and uncontrolled use of blood products such as fresh frozen plasma, red blood cells, and platelets without POC monitoring should no longer be followed with regard to actual evidence in literature. Furthermore, the use of factor concentrates may provide better outcomes and potential for cost saving.
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Affiliation(s)
- Oliver M Theusinger
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Philipp Stein
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Jerrold H Levy
- Cardiothoracic ICU, Duke University School of Medicine, Durham, NC, USA
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170
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Abstract
PURPOSE OF REVIEW There exists an imbalance between our understanding of the physiology of the blood coagulation process and the translation of this understanding into useful assays for clinical application. As technology advances, the capabilities for merging the two areas have become more attainable. Global assays have advanced our understanding of the dynamics of the blood coagulation process beyond end point assays and are at the forefront of implementation in the clinic. RECENT FINDINGS We will review recent advances in the main global assays with a focus on thrombin generation that have potential for clinical utility. These assays include direct (thrombogram, whole blood, purified systems) and indirect empirical measures of thrombin generation (thromboelastography) and mechanism-based computational models that use plasma composition data from individuals to generate thrombin generation profiles. SUMMARY Empirical thrombin generation assays (direct and indirect) and computational modeling of thrombin generation have greatly advanced our understanding of the hemostatic balance. Implementation of these types of assays and visualization approaches in the clinic will potentially provide a basis for the development of individualized patient care. Advances in both empirical and computational global assays have made the goal of predicting precrisis changes in an individual's hemostatic state one step closer.
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171
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Tynngård N, Lindahl TL, Ramström S. Assays of different aspects of haemostasis - what do they measure? Thromb J 2015; 13:8. [PMID: 25688179 PMCID: PMC4329663 DOI: 10.1186/s12959-015-0036-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 01/12/2015] [Indexed: 12/25/2022] Open
Abstract
Haemostasis is a complex process affected by many factors including both cellular and plasma components. It is a multistep process starting with platelet adhesion to damaged endothelium and ending in clot fibrinolysis. There are several methods available to study different aspects of haemostasis including adhesion, aggregation, coagulation and fibrinolysis. This review describes the different methods, what aspects of haemostasis they measure and their limitations. Methods discussed include methods to study adhesion (e.g. PFA-100, cone and platelet(let) analyzer and perfusion chambers) and aggregation (e.g. Multiplate, VerifyNow and Plateletworks). Furthermore the principles behind viscoelastic haemostatic assays are presented as well as methods that can analyse aspects of haemostasis in plasma or platelet-rich-plasma samples (thrombin generation, overall haemostasis potential and Thrombodynamics Analyzer).
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Affiliation(s)
- Nahreen Tynngård
- Department of Clinical Chemistry, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden ; Department of Clinical Immunology and Transfusion Medicine, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Tomas L Lindahl
- Department of Clinical Chemistry, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Sofia Ramström
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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172
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Lancé MD. A general review of major global coagulation assays: thrombelastography, thrombin generation test and clot waveform analysis. Thromb J 2015; 13:1. [PMID: 25937820 PMCID: PMC4417204 DOI: 10.1186/1477-9560-13-1] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 06/16/2014] [Indexed: 01/08/2023] Open
Abstract
Thrombosis and hemorrhage are major contributors to morbidity and mortality. The traditional laboratory tests do not supply enough information to diagnose and treat patients timely and according to their phenotype. Global hemostasis tests might improve this circumstance. The viscoelastic tests (ROTEM/TEG) demonstrated to ameliorate treatment of acute hemorrhage in terms of decreased amount of transfusion and lowered costs. Thrombin generation measurement is indicative for thrombosis and might also become an important tool in managing hemorrhage. While the clot waveform analysis is less well known it could be of worth in staging sepsis patients, early detection of DIC and also in diagnosis and treatment monitoring of hemophiliac patients. Although in different degree all three methods still need more background, standardization and acceptance before a wide clinical application.
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Affiliation(s)
- Marcus D Lancé
- Department of Anesthesiology and Pain Treatment, Maastricht University Medical Center, P. Debyelaan 25, PO box 5800, 6202 AZ Maastricht, The Netherlands
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173
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Whitfield P, Williams A, Nokes T. Managing coagulopathy and thromboprophylaxis in the neurosurgical patient. ADVANCES IN CLINICAL NEUROSCIENCE & REHABILITATION 2015. [DOI: 10.47795/stkk4952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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174
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Saner FH. Rotational thrombelastometry: a step forward to safer patient care? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:706. [PMID: 25672525 PMCID: PMC4331150 DOI: 10.1186/s13054-014-0706-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The study by Hincker and colleagues indicated that the perioperative use of rotational thrombelastometry (ROTEM™) could predict thromboembolic events in 90% of the cases in non-cardiac surgery. Viscoelastic tests (VETs)--ROTEM™ and thrombelastography (TEG™)--are used mainly to predict bleeding complications. Most conventional coagulation tests, like prothrombin time and activated partial thromboplastin time, can identify a disturbance in plasmatic hemostasis. However, the relevance of these assays is limited to the initiation phase of coagulation, whereas VETs are designed to assess the whole clotting kinetics and strength of the whole blood clot and reflect more the interaction between procoagulants, anticoagulants, and platelets. The first reports about VET and hypercoagulable state were published more than 25 years ago. Since then, several studies with different quality and sample size have been published, sometimes with conflicting results. A systematic review about hypercoagulable state and TEG™ indicated that further studies are needed to recommend VETs as a screening tool to predict postoperative thrombosis.
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175
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Anderson L, Quasim I, Steven M, Moise SF, Shelley B, Schraag S, Sinclair A. Interoperator and Intraoperator Variability of Whole Blood Coagulation Assays: A Comparison of Thromboelastography and Rotational Thromboelastometry. J Cardiothorac Vasc Anesth 2014; 28:1550-7. [DOI: 10.1053/j.jvca.2014.05.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Indexed: 11/11/2022]
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176
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Utility of thromboelastography in traumatic brain injury and the neuroscience intensive care unit. J Neurosci Nurs 2014; 46:66-70. [PMID: 24556653 DOI: 10.1097/jnn.0000000000000045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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177
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Abstract
Thrombin has multiple functions in blood coagulation and its regulation is central to maintaining the balance between hemorrhage and thrombosis. Empirical and computational methods that capture thrombin generation can provide advancements to current clinical screening of the hemostatic balance at the level of the individual. In any individual, procoagulant and anticoagulant factor levels together act to generate a unique coagulation phenotype (net balance) that is reflective of the sum of its developmental, environmental, genetic, nutritional and pharmacological influences. Defining such thrombin phenotypes may provide a means to track disease progression pre-crisis. In this review we briefly describe thrombin function, methods for assessing thrombin dynamics as a phenotypic marker, computationally derived thrombin phenotypes versus determined clinical phenotypes, the boundaries of normal range thrombin generation using plasma composition based approaches and the feasibility of these approaches for predicting risk.
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178
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Denault A, Lamarche Y, Rochon A, Cogan J, Liszkowski M, Lebon JS, Ayoub C, Taillefer J, Blain R, Viens C, Couture P, Deschamps A. Innovative approaches in the perioperative care of the cardiac surgical patient in the operating room and intensive care unit. Can J Cardiol 2014; 30:S459-77. [PMID: 25432139 DOI: 10.1016/j.cjca.2014.09.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/11/2014] [Accepted: 09/24/2014] [Indexed: 02/07/2023] Open
Abstract
Perioperative care for cardiac surgery is undergoing rapid evolution. Many of the changes involve the application of novel technologies to tackle common challenges in optimizing perioperative management. Herein, we illustrate recent advances in perioperative management by focusing on a number of novel components that we judge to be particularly important. These include: the introduction of brain and somatic oximetry; transesophageal echocardiographic hemodynamic monitoring and bedside focused ultrasound; ultrasound-guided vascular access; point-of-care coagulation surveillance; right ventricular pressure monitoring; novel inhaled treatment for right ventricular failure; new approaches for postoperative pain management; novel approaches in specialized care procedures to ensure quality control; and specific approaches to optimize the management for postoperative cardiac arrest. Herein, we discuss the reasons that each of these components are particularly important in improving perioperative care, describe how they can be addressed, and their impact in the care of patients who undergo cardiac surgery.
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Affiliation(s)
- André Denault
- Department of Anesthesiology, Critical Care Program, Montreal Heart Institute, and Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Quebec, Canada.
| | - Yoan Lamarche
- Department of Cardiac Surgery and Critical Care Program, Montreal Heart Institute, and Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Antoine Rochon
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jennifer Cogan
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Mark Liszkowski
- Department of Medicine, Cardiology and Critical Care Program, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-Sébastien Lebon
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Christian Ayoub
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jean Taillefer
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Robert Blain
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Claudia Viens
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Pierre Couture
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Alain Deschamps
- Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
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179
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Tanriverdi S, Koroglu OA, Uygur O, Balkan C, Yalaz M, Kultursay N. The effect of inhaled nitric oxide therapy on thromboelastogram in newborns with persistent pulmonary hypertension. Eur J Pediatr 2014; 173:1381-5. [PMID: 24791933 DOI: 10.1007/s00431-014-2325-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 04/16/2014] [Accepted: 04/17/2014] [Indexed: 12/01/2022]
Abstract
UNLABELLED Studies about the effects of inhaled nitric oxide (iNO) on bleeding time and platelet aggregation in newborns are limited in number and have inconclusive results. Thromboelastogram (TEG) shows the combined effects of coagulation factors and platelet functions. In this preliminary study, we aimed to evaluate the effects of iNO on coagulation using TEG in newborns with persistent pulmonary hypertension (PPH). TEG assays were performed in 10 term infants receiving iNO treatment for PPH and 32 healthy term infants. Samples of the iNO group were collected before and during iNO. Clot reaction time (R), clot kinetics (K), maximum amplitude (MA), and alpha angle were obtained from the TEG tracing. TEG-R values were statistically higher during iNO treatment (7.75 ± 3.34) when compared to the values before iNO (4.83 ± 1.38) and the healthy controls (3.75 ± 0.98). The alpha angle was lower in iNO treated infants at both periods (before iNO, 55.33 ± 8.58; during iNO, 42.90 ± 18.34) compared to the control group (64.95 ± 6.88). MA values before iNO treatment were the lowest (44.43 ± 14.09) and improved with the iNO treatment (48.40 ± 9.49) despite still being lower compared to the controls (53.67 ± 5.56). CONCLUSION Both PPH and iNO may negatively effect in vitro coagulation tests. Therefore, newborns with PPH requiring iNO treatment should be closely monitored for coagulation problems.
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Affiliation(s)
- Sema Tanriverdi
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Ege University, Bornova, 35100, Izmir, Turkey,
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180
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Tripodi A. A(nother) Test Meant to Fill the Gap between In Vivo and Ex Vivo Hemostasis. Clin Chem 2014; 60:1137-40. [DOI: 10.1373/clinchem.2014.227884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milan, Italy
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181
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van Ryn J, Grottke O, Spronk H. Measurement of dabigatran in standardly used clinical assays, whole blood viscoelastic coagulation, and thrombin generation assays. Clin Lab Med 2014; 34:479-501. [PMID: 25168938 DOI: 10.1016/j.cll.2014.06.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Dabigatran, a direct thrombin inhibitor, is increasingly used clinically as one of the new oral anticoagulants. This review summarizes the assays available to measure its activity and includes the relative sensitivity of the different assays for this agent. In addition to plasma-based clotting tests, assays commonly used in surgical/emergency settings, such as activated clotting time and thromboelastometry/thromboelastography, are reviewed. In addition, the thrombin generation assay is discussed as an important method to determine the potential risk of thrombosis or bleeding and its relevance to the measurement of direct thrombin inhibitors.
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Affiliation(s)
- Joanne van Ryn
- Department of CardioMetabolic Disease Research, Boehringer Ingelheim Pharma GmbH & Co KG, Birkendorfer Street 65, Biberach 88397, Germany.
| | - Oliver Grottke
- Department of Anesthesiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, Aachen 52074, Germany
| | - Henri Spronk
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, PO Box 616, Maastricht 6200 MD, The Netherlands
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182
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Sommerey CC, Williams TL, McCrone I, Ruiz-Ferreras A, Freeman D, Archer J. Thromboelastography in healthy dairy cows. J Dairy Sci 2014; 97:5474-80. [PMID: 24997666 DOI: 10.3168/jds.2014-7909] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 06/02/2014] [Indexed: 11/19/2022]
Abstract
Thromboelastography is a whole blood-based coagulation assay that can be used to investigate hypocoagulability and hypercoagulability, as seen with thromboembolic diseases and disseminated intravascular coagulation. Numerous coagulopathies due to different causes are reported in cows. The objective was to establish reference intervals for thromboelastography using the TEG 5000 (Haemonetics GmbH, Munich, Germany) with citrated whole blood samples and kaolin activation in dairy cows and to investigate possible thromboelastographic changes between cows in different lactation periods. An additional objective was to test the stability of samples for up to 100h. Sixty blood samples from healthy Holstein-Friesian cows were examined. The samples were allocated to 3 different lactation groups (≤30 d postcalving, 31-99 d postcalving, ≥100 d postcalving). Thromboelastography was performed by using the TEG 5000 analyzer with citrated whole blood samples with kaolin activation. The calculated reference intervals were as follows: reaction time=2.2 to 6.2min, coagulation time=0.8 to 2.0min, angle α=58.2 to 81.8°, maximum amplitude=64.3 to 89.2mm, and clot rigidity=9.2 to 41.2 dyn/cm(2). The 3 different lactation groups showed no significant differences in TEG parameters. No significant difference was seen in samples stored for up to 48h at room temperature, which indicates that delays in processing samples, such as those arising during transit, are not an issue.
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Affiliation(s)
- Cora-Costanze Sommerey
- Department of Veterinary Medicine, University of Cambridge, Cambridge CB3 0ES, United Kingdom.
| | - Tim L Williams
- Department of Veterinary Medicine, University of Cambridge, Cambridge CB3 0ES, United Kingdom
| | - Ian McCrone
- Department of Veterinary Medicine, University of Cambridge, Cambridge CB3 0ES, United Kingdom
| | - Aran Ruiz-Ferreras
- Department of Veterinary Medicine, University of Cambridge, Cambridge CB3 0ES, United Kingdom
| | - Dan Freeman
- Department of Veterinary Medicine, University of Cambridge, Cambridge CB3 0ES, United Kingdom
| | - Joy Archer
- Department of Veterinary Medicine, University of Cambridge, Cambridge CB3 0ES, United Kingdom
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183
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Klamroth R. Abklärung einer erworbenen Blutungsneigung. Internist (Berl) 2014; 55:514-20. [DOI: 10.1007/s00108-013-3421-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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184
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Sun W, Jeleniowski K, Zhao X, Shen P, Li D, Hammond JA. Thromboelastography (TEG)-Based Algorithm Reduces Blood Product Utilization in Patients Undergoing VAD Implant. J Card Surg 2014; 29:238-43. [PMID: 24734284 DOI: 10.1111/jocs.12302] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Wenyu Sun
- Department of Cardiovascular Surgery; Qilu Hospital, Shandong University; Jinan P.R. China
| | - Ken Jeleniowski
- Department of Perfusion; Hartford Hospital; Hartford Connecticut
| | - Xin Zhao
- Department of Cardiovascular Surgery; Qilu Hospital, Shandong University; Jinan P.R. China
| | - Peter Shen
- Department of Cytopathology; Hartford Hospital; Hartford Connecticut
| | - Dadong Li
- Department of Research Administration; Hartford Hospital; Hartford Connecticut
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185
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Whiting D, DiNardo JA. TEG and ROTEM: technology and clinical applications. Am J Hematol 2014; 89:228-32. [PMID: 24123050 DOI: 10.1002/ajh.23599] [Citation(s) in RCA: 404] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 09/23/2013] [Accepted: 09/23/2013] [Indexed: 12/13/2022]
Abstract
Initially described in 1948 by Hertert thromboelastography (TEG) provides a real-time assessment of viscoelastic clot strength in whole blood. Rotational thromboelastometry (ROTEM) evolved from TEG technology and both devices generate output by transducing changes in the viscoelastic strength of a small sample of clotting blood (300 µl) to which a constant rotational force is applied. These point of care devices allow visual assessment of blood coagulation from clot formation, through propagation, and stabilization, until clot dissolution. Computer analysis of the output allows sophisticated clot formation/dissolution kinetics and clot strength data to be generated. Activation of clot formation can be initiated with both intrinsic (kaolin, ellagic acid) and extrinsic (tissue factor) activators. In addition, the independent contributions of platelets and fibrinogen to final clot strength can be assessed using added platelet inhibitors (abciximab and cytochalasin D). Increasingly, ROTEM and TEG analysis is being incorporated in vertical algorithms to diagnose and treat bleeding in high-risk populations such as those undergoing cardiac surgery or suffering from blunt trauma. Some evidence suggests these algorithms might reduce transfusions, but further study is needed to assess patient outcomes.
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Affiliation(s)
- David Whiting
- Division of Cardiac Anesthesia, Department of Anaesthesia; Perioperative and Pain Medicine, Boston Children's Hospital; Boston Massachusetts
| | - James A. DiNardo
- Division of Cardiac Anesthesia, Department of Anaesthesia; Perioperative and Pain Medicine, Boston Children's Hospital; Boston Massachusetts
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186
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Thorson CM, Van Haren RM, Ryan ML, Curia E, Sleeman D, Levi JU, Livingstone AS, Proctor KG. Pre-existing hypercoagulability in patients undergoing potentially curative cancer resection. Surgery 2013; 155:134-44. [PMID: 24238121 DOI: 10.1016/j.surg.2013.06.053] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 06/28/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rotational thromboelastometry (ROTEM) is a new point-of-care test that allows a rapid and comprehensive evaluation of coagulation. We were among the first to show that ROTEM identifies baseline hypercoagulability in 40% of patients with intra-abdominal malignancies and that hypercoagulability persists for ≥1 month after resection. The purpose of this follow-up study was to confirm and extend these observations to a larger population in outpatient preoperative clinics. The hypothesis is that pre-existing hypercoagulability is present in patients undergoing surgery for malignant disease and that coagulation status varies by tumor type. METHODS After informed consent, preoperative blood samples were drawn from patients undergoing exploratory laparotomies for intra-abdominal malignancies and analyzed with ROTEM. RESULTS Eighty-two patients were enrolled, including 72 with a confirmed pathologic diagnosis and 10 age-matched controls with benign disease. The most common cancers involved the pancreas (n = 23; 32%), esophagus (n = 19; 26%), liver (n = 12; 17%), stomach (n = 7; 10%), and bile ducts (n = 5; 7%). Preoperative hypercoagulability was detected in 31% (n = 22); these patients were more likely to have lymphovascular invasion (88% vs 50%; P = .011), perineural invasion (77% vs 36%; P = .007), and stage III/IV disease (80% vs 62%; P = .039). More patients with pancreatic tumors (9/23, 39%) were hypercoagulable than with esophageal (3/19, 16%) or liver (2/13, 15%, P = .034) tumors. When only resectable malignancies were considered, clot formation was more rapid (low clot formation time, high alpha) with enhanced maximum clot strength (high maximum clot firmness) in pancreatic versus esophageal or liver cancers and in all cancers versus those with benign disease. CONCLUSION Preoperative hypercoagulability can be identified with ROTEM and is associated with lymphovascular/perineural invasion and advanced-staged disease in cancer. Compared with other tumor types, pancreatic adenocarcinomas have the greatest risk for hypercoagulability.
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Affiliation(s)
- Chad M Thorson
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Robert M Van Haren
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Mark L Ryan
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Emiliano Curia
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Danny Sleeman
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Joe U Levi
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Alan S Livingstone
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL
| | - Kenneth G Proctor
- Divisions of Surgical Oncology, General Surgery, Trauma, and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, FL.
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187
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Bitar A, Kreutz RP. Role of Thrombelastography (TEG) in Risk Assessment and Guidance of Antithrombotic Therapy in Patients with Coronary Artery Disease. Drug Dev Res 2013. [DOI: 10.1002/ddr.21112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Abbas Bitar
- Krannert Institute of Cardiology; Indiana University School of Medicine; Indianapolis IN USA
| | - Rolf P. Kreutz
- Krannert Institute of Cardiology; Indiana University School of Medicine; Indianapolis IN USA
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Kolbenschlag J, Daigeler A, Lauer S, Wittenberg G, Fischer S, Kapalschinski N, Lehnhardt M, Goertz O. Can rotational thromboelastometry predict thrombotic complications in reconstructive microsurgery? Microsurgery 2013; 34:253-60. [DOI: 10.1002/micr.22199] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 10/03/2013] [Accepted: 10/04/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Jonas Kolbenschlag
- BG University Clinic Bergmannsheil; Department of Plastic Surgery, Burn Center; Bochum Germany
| | - Adrien Daigeler
- BG University Clinic Bergmannsheil; Department of Plastic Surgery, Burn Center; Bochum Germany
| | - Sarah Lauer
- BG Trauma Center; Department of Plastic and Hand Surgery; Ludwigshafen Germany
| | - Gerhard Wittenberg
- BG Trauma Center; Department of Anaesthesiology and Intensive Care Medicine; Ludwigshafen Germany
| | - Sebastian Fischer
- BG Trauma Center; Department of Plastic and Hand Surgery; Ludwigshafen Germany
| | - Nicolai Kapalschinski
- BG University Clinic Bergmannsheil; Department of Plastic Surgery, Burn Center; Bochum Germany
| | - Marcus Lehnhardt
- BG University Clinic Bergmannsheil; Department of Plastic Surgery, Burn Center; Bochum Germany
| | - Ole Goertz
- BG University Clinic Bergmannsheil; Department of Plastic Surgery, Burn Center; Bochum Germany
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189
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Point of Care Testing in Cardiac Surgery: Diagnostic Modalities to Assess Coagulation and Platelet Function. Drug Dev Res 2013. [DOI: 10.1002/ddr.21099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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190
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Toukh M, Siemens DR, Black A, Robb S, Leveridge M, Graham CH, Othman M. Thromboelastography identifies hypercoagulablilty and predicts thromboembolic complications in patients with prostate cancer. Thromb Res 2013; 133:88-95. [PMID: 24246296 DOI: 10.1016/j.thromres.2013.10.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 09/26/2013] [Accepted: 10/01/2013] [Indexed: 11/30/2022]
Abstract
Cancer patients are at higher risk for thromboembolism compared to the normal population. This may be related to tumour burden and/or enhanced by systemic therapy. While there is ample evidence regarding venous thromboembolism, systematic studies investigating arterial thrombotic events are scarce. Conventional coagulation tests have limited capacity in evaluating the coagulability or the need for anticoagulant prophylaxis. In this pilot study, we investigated whether assessment of global haemostasis using thromboelastography (TEG) and quantification of plasma pro-coagulant microparticles can help determine the risk of adverse thrombotic events in patients with prostate cancer (PCa). Thirty two patients were recruited a priori into three groups: 11 men on 'watchful waiting' following recurrent disease after definitive treatment (Group A); 10 patients with metastatic disease on Androgen deprivation therapy (ADT) (Group B); and 11 with castration resistant cancer (Group C) and followed up over a period of 12months. These patients were compared to a control group composed of 8 men with negative prostate biopsy. Whole blood TEG and plasma tissue factor-carrying microparticles (TF-MPs) in addition to basic coagulation testing, plasma fibrinogen and d-dimer were performed. 22/32 (68.8%) of the patients demonstrated hypercoagulable TEG traces. Hypercoagulability was marked in group B compared to the control. Plasma MPs were significantly elevated in patients compared to the controls with significant increase in group B. All other coagulation tests were normal. Seven of the 22 hypercoagulable patients (31.8%) developed one or more thromboembolic events over 12months follow up period. The data in this pilot study show that PCa patients are hypercoagulable, particularly those with advanced disease on ADT and that this hypercoagulability can be identified by TEG. While this needs to be verified in a larger study, the data indicate TEG may aid in thrombosis risk stratification and determining the subsequent need for anticoagulant prophylaxis in PCa patients.
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Affiliation(s)
- Mazen Toukh
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - D Robert Siemens
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada; Department of Urology, Queen's University, Kingston, Ontario, Canada
| | - Angela Black
- Department of Urology, Queen's University, Kingston, Ontario, Canada
| | - Sylvia Robb
- Department of Urology, Queen's University, Kingston, Ontario, Canada
| | - Michael Leveridge
- Department of Urology, Queen's University, Kingston, Ontario, Canada
| | - Charles H Graham
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada; St Lawrence College, Kingston, Ontario, Canada.
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191
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Grossmann E, Akyol D, Eder L, Hofmann B, Haneya A, Graf BM, Bucher M, Raspé C. Thromboelastometric detection of clotting Factor XIII deficiency in cardiac surgery patients. Transfus Med 2013; 23:407-15. [DOI: 10.1111/tme.12069] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 02/15/2013] [Accepted: 03/10/2013] [Indexed: 11/30/2022]
Affiliation(s)
- E. Grossmann
- Abteilung für Anästhesie; Herzzentrum Leipzig GmbH; Struempelstrasse 39 04289 Leipzig Germany
| | - D. Akyol
- Department of Anesthesiology; Regensburg University; Regensburg Germany
| | - L. Eder
- Abteilung für Anästhesie; Herzzentrum Leipzig GmbH; Struempelstrasse 39 04289 Leipzig Germany
| | - B. Hofmann
- Department of Cardiothoracic Surgery; Halle-Wittenberg University; Halle Germany
| | - A. Haneya
- Department of Cardiothoracic Surgery; Regensburg University; Regensburg Germany
| | - B. M. Graf
- Department of Anesthesiology; Regensburg University; Regensburg Germany
| | - M. Bucher
- Abteilung für Anästhesie; Herzzentrum Leipzig GmbH; Struempelstrasse 39 04289 Leipzig Germany
| | - C. Raspé
- Abteilung für Anästhesie; Herzzentrum Leipzig GmbH; Struempelstrasse 39 04289 Leipzig Germany
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192
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Mallett SV, Chowdary P, Burroughs AK. Clinical utility of viscoelastic tests of coagulation in patients with liver disease. Liver Int 2013; 33:961-74. [PMID: 23638693 DOI: 10.1111/liv.12158] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 02/28/2013] [Indexed: 12/18/2022]
Abstract
The prothrombin time (PT) and international normalised ratio (INR) are used in scoring systems (Child-Pugh, MELD, UKELD) in chronic liver disease and as a prognostic tool and for dynamic monitoring of hepatic function in acute liver disease. These tests are known to be poor predictors of bleeding risk in liver disease; however, they continue to influence clinical management decisions. Recent work on coagulation in liver disease, in particular thrombin generation studies, has led to a paradigm shift in our understanding and it is now recognised that haemostasis is relatively well preserved. Whole blood global viscoelastic tests (TEG(®) /ROTEM(®) ) produce a composite dynamic picture of the entire coagulation process and have the potential to provide more clinically relevant information in patients with liver disease. We performed a systematic review of all relevant studies that have used viscoelastic tests (VET) of coagulation in patients with liver disease. Although many studies are observational and small in size, it is clear that VET provide additional information that is in keeping with the new concepts of how coagulation is altered in these patients. This review provides the basis for large scale, prospective outcome studies to establish the clinical value of these tests.
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Affiliation(s)
- Susan V Mallett
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
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193
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194
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Kumar A, Auron M, Ereth M. Blood management. Anesthesiol Clin 2013; 31:433-50. [PMID: 23711652 DOI: 10.1016/j.anclin.2013.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Blood management is a system-based comprehensive approach that uses evidence-based medicine to facilitate an environment to encourage an appropriate use of blood products in the hospital setting. The ultimate goal of a blood-management program is to improve patient outcomes by integrating all available techniques to ensure safety, availability, and appropriate allocation of blood products. It is a patient-centered, multidisciplinary, multimodal, planned approach to the management of patients and blood products.
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Affiliation(s)
- Ajay Kumar
- Division of Hospital Medicine, Hartford Hospital, Hartford, CT, USA.
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195
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Tran R, Myers DR, Ciciliano J, Trybus Hardy EL, Sakurai Y, Ahn B, Qiu Y, Mannino RG, Fay ME, Lam WA. Biomechanics of haemostasis and thrombosis in health and disease: from the macro- to molecular scale. J Cell Mol Med 2013; 17:579-96. [PMID: 23490277 PMCID: PMC3822810 DOI: 10.1111/jcmm.12041] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/24/2013] [Indexed: 11/28/2022] Open
Abstract
Although the processes of haemostasis and thrombosis have been studied extensively in the past several decades, much of the effort has been spent characterizing the biological and biochemical aspects of clotting. More recently, researchers have discovered that the function and physiology of blood cells and plasma proteins relevant in haematologic processes are mechanically, as well as biologically, regulated. This is not entirely surprising considering the extremely dynamic fluidic environment that these blood components exist in. Other cells in the body such as fibroblasts and endothelial cells have been found to biologically respond to their physical and mechanical environments, affecting aspects of cellular physiology as diverse as cytoskeletal architecture to gene expression to alterations of vital signalling pathways. In the circulation, blood cells and plasma proteins are constantly exposed to forces while they, in turn, also exert forces to regulate clot formation. These mechanical factors lead to biochemical and biomechanical changes on the macro- to molecular scale. Likewise, biochemical and biomechanical alterations in the microenvironment can ultimately impact the mechanical regulation of clot formation. The ways in which these factors all balance each other can be the difference between haemostasis and thrombosis. Here, we review how the biomechanics of blood cells intimately interact with the cellular and molecular biology to regulate haemostasis and thrombosis in the context of health and disease from the macro- to molecular scale. We will also show how these biomechanical forces in the context of haemostasis and thrombosis have been replicated or measured in vitro.
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Affiliation(s)
- Reginald Tran
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Aflac Cancer Center and Blood Disorders Service of Children's Healthcare of Atlanta, Emory University School of MedicineAtlanta, Georgia, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory UniversityAtlanta, Georgia, USA
- Winship Cancer Institute of Emory UniversityAtlanta, Georgia, USA
| | - David R Myers
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Aflac Cancer Center and Blood Disorders Service of Children's Healthcare of Atlanta, Emory University School of MedicineAtlanta, Georgia, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory UniversityAtlanta, Georgia, USA
- Winship Cancer Institute of Emory UniversityAtlanta, Georgia, USA
| | - Jordan Ciciliano
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Aflac Cancer Center and Blood Disorders Service of Children's Healthcare of Atlanta, Emory University School of MedicineAtlanta, Georgia, USA
- Parker H. Petit Institute of Bioengineering & Bioscience, Georgia Institute of TechnologyAtlanta, Georgia, USA
- Winship Cancer Institute of Emory UniversityAtlanta, Georgia, USA
| | - Elaissa L Trybus Hardy
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Aflac Cancer Center and Blood Disorders Service of Children's Healthcare of Atlanta, Emory University School of MedicineAtlanta, Georgia, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory UniversityAtlanta, Georgia, USA
- Winship Cancer Institute of Emory UniversityAtlanta, Georgia, USA
| | - Yumiko Sakurai
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Aflac Cancer Center and Blood Disorders Service of Children's Healthcare of Atlanta, Emory University School of MedicineAtlanta, Georgia, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory UniversityAtlanta, Georgia, USA
- Winship Cancer Institute of Emory UniversityAtlanta, Georgia, USA
| | - Byungwook Ahn
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Aflac Cancer Center and Blood Disorders Service of Children's Healthcare of Atlanta, Emory University School of MedicineAtlanta, Georgia, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory UniversityAtlanta, Georgia, USA
- Winship Cancer Institute of Emory UniversityAtlanta, Georgia, USA
| | - Yongzhi Qiu
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Aflac Cancer Center and Blood Disorders Service of Children's Healthcare of Atlanta, Emory University School of MedicineAtlanta, Georgia, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory UniversityAtlanta, Georgia, USA
- Winship Cancer Institute of Emory UniversityAtlanta, Georgia, USA
| | - Robert G Mannino
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory UniversityAtlanta, Georgia, USA
| | - Meredith E Fay
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory UniversityAtlanta, Georgia, USA
| | - Wilbur A Lam
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Aflac Cancer Center and Blood Disorders Service of Children's Healthcare of Atlanta, Emory University School of MedicineAtlanta, Georgia, USA
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory UniversityAtlanta, Georgia, USA
- Parker H. Petit Institute of Bioengineering & Bioscience, Georgia Institute of TechnologyAtlanta, Georgia, USA
- Winship Cancer Institute of Emory UniversityAtlanta, Georgia, USA
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196
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da Luz LT, Nascimento B, Rizoli S. Thrombelastography (TEG®): practical considerations on its clinical use in trauma resuscitation. Scand J Trauma Resusc Emerg Med 2013; 21:29. [PMID: 23587157 PMCID: PMC3637505 DOI: 10.1186/1757-7241-21-29] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 04/07/2013] [Indexed: 01/06/2023] Open
Abstract
Background Thrombelastography is a laboratorial test that measures viscoelastic changes of the entire clotting process. There is growing interest in its clinical use in trauma resuscitation, particularly for managing acute coagulopathy of trauma and assisting decision making concerning transfusion. This review focuses on the clinical use of thrombelastography in trauma, with practical points to consider on its use in civilian and military settings. Methods A search in the literature using the terms “thrombelastography AND trauma” was performed in PUBMED database. We focused the review on the main clinical aspects of this viscoelastic method in diagnosing and treating patients with acute coagulopathy of trauma during initial resuscitation. Results Thrombelastography is not a substitute for conventional laboratorial tests such as INR and aPTT but offers additional information and may guide blood transfusion. Thrombelastography can be used as a point of care test but requires multiple daily calibrations, should be performed by trained personnel and its technique requires standardization. While useful partial results may be available in minutes, the whole test may take as long as other conventional tests. The most important data provided by thrombelastography are clot strength and fibrinolysis. Clot strength measure can establish whether the bleeding is due to coagulopathy or not, and is the key information in thrombelastography-based transfusion algorithms. Thrombelastography is among the few tests that diagnose and quantify fibrinolysis and thus guide the use of anti-fibrinolytic drugs and blood products such as cryoprecipitate and fibrinogen concentrate. It may also diagnose platelet dysfunction and hypercoagulability and potentially prevent inappropriate transfusions of hemostatic blood products to non-coagulopathic patients. Conclusions Thrombelastography has characteristics of an ideal coagulation test for use in early trauma resuscitation. It has limitations, but may prove useful as an additional test. Future studies should evaluate its potential to guide blood transfusion and the understanding of the mechanisms of trauma coagulopathy.
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Affiliation(s)
- Luis Teodoro da Luz
- Department of Critical Care Medicine, Sunnybrook Health Science Centre, University of Toronto, Toronto, ON, Canada
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197
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Persistence of Hypercoagulable State after Resection of Intra-Abdominal Malignancies. J Am Coll Surg 2013; 216:580-9; discussion 589-90. [DOI: 10.1016/j.jamcollsurg.2012.12.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 12/07/2012] [Indexed: 11/23/2022]
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198
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Ko RH, Ji L, Young G. A novel approach for detecting hypercoagulability utilizing thromboelastography. Thromb Res 2013; 131:352-6. [PMID: 23419411 DOI: 10.1016/j.thromres.2013.01.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 12/25/2012] [Accepted: 01/24/2013] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The thromboelastograph is a point-of-care, global hemostasis assay that measures the dynamics of clot formation, including physical properties, over time and is licensed for use in monitoring coagulation during complex surgical procedures. It has more recently been used as a research tool to investigate various bleeding and clotting disorders. Although attempts have been made to use thromboelastography to detect hypercoagulable states, thus far a consistent, reliable approach has not been discovered. The objective of this study was to develop a novel approach utilizing thromboelastography that is sensitive for detecting hypercoagulability. MATERIALS AND METHODS Healthy, adult volunteers provided blood samples that were subjected to pre-analytic modifications from standard thromboelastography methods with the goal of prolonging clot initiation and propagation times. The methods which resulted in the desired changes in a consistent and reliable manner utilized corn trypsin inhibitor, a contact pathway inhibitor, on unactivated blood samples. To demonstrate that these methods are sensitive to detecting hypercoagulability, increasing concentrations of recombinant human thrombin were added as a surrogate for hypercoagulability. RESULTS Our methods were able to consistently and statistically significantly change the baseline TEG parameters of R time, K time, and angle in the desired fashion. Additionally, these methods were able to detect increasing concentrations of thrombin. CONCLUSIONS We describe a novel approach in which thromboelastography is highly sensitive to detecting increasing concentrations of thrombin in vitro. Further studies are underway to determine if these methods will be sensitive for detecting hypercoagulable states in vivo.
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Affiliation(s)
- Richard H Ko
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA 90027, United States.
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199
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Ågren A, Wikman AT, Holmström M, Östlund A, Edgren G. Thromboelastography (TEG®) compared to conventional coagulation tests in surgical patients – a laboratory evaluation. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:214-20. [DOI: 10.3109/00365513.2013.765960] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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200
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Thrombin generation and whole blood viscoelastic assays in the management of hemophilia: current state of art and future perspectives. Blood 2013; 121:1944-50. [PMID: 23319573 DOI: 10.1182/blood-2012-08-378935] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Hemophilia is a bleeding disorder that afflicts about 1 in 5000 males. Treatment relies upon replacement of the deficient factor, and response to treatment both in clinical research and practice is based upon subjective parameters such as pain and joint mobility. Existing laboratory assays quantify the amount of factor in plasma, which is useful diagnostically and prognostically. However, these assays are limited in their ability to fully evaluate the patient's clot-forming capability. Newer assays, known as global assays, provide a far more detailed view of thrombin generation and clot formation and have been studied in hemophilia for about 10 years. They have the potential to offer a more objective measure of both the hemophilic phenotype as well as the response to treatment. In particular, in patients who develop inhibitors to deficient clotting factors and in whom bypassing agents are required for hemostasis, these assays offer the opportunity to determine the laboratory response to these interventions where traditional coagulation assays cannot. In this article we review the existing literature and discuss several controversial issues surrounding the assays. Last, a vision of future clinical uses of these assays is briefly described.
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