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Auty T, McCullough J, Hughes I, Fanning JP, Czuchwicki S, Winearls J. Fibrinogen levels in severe trauma: A preliminary comparison of Clauss Fibrinogen, ROTEM Sigma, ROTEM Delta and TEG 6s assays from the FEISTY pilot randomised clinical trial. Emerg Med Australas 2024; 36:363-370. [PMID: 38196013 DOI: 10.1111/1742-6723.14356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/19/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE To describe the relationships between different methods of measuring functional fibrinogen levels in severely injured, bleeding trauma patients across multiple timepoints during hospitalisation. METHODS In 100 adult trauma patients enrolled in the FEISTY pilot randomised clinical trial at four tertiary trauma centres in Australia, blood samples were collected prospectively. Consistency of agreement was calculated, comparing functional fibrinogen levels measured by four methods - ROTEM® Delta and Sigma FIBTEM A5, TEG® 6s CFF MA, and gold-standard Clauss Fibrinogen. RESULTS Comparing the ROTEM® Delta and new-generation ROTEM® Sigma machine, consistency of agreement for FIBTEM A5, measured by calculating intraclass correlation coefficients (ICCs), was ≥0.73 across all analysed timepoints, with mean differences (Sigma minus Delta) of 0.10-3.57 mm. Corresponding values comparing the ROTEM® Sigma FIBTEM A5 and TEG® 6s CFF MA were ICC = 0.55-0.82 and ICC = 4.69-7.97 (CFF MA minus A5). Comparing ROTEM® Sigma FIBTEM A5 and Clauss Fibrinogen Analysis (CFA), among statistically significant simple linear regression models, R2 was 0.25-0.67, and comparing TEG® 6s CFF MA and CFA (CFA) 0.65-0.82, although not all differences were significant with the latter comparison. Relationships across all timepoints combined were Clauss Fibrinogen (CF) (g/L) = 0.21𝑥 + 0.004 (where 𝑥 = ROTEM® Sigma FIBTEM A5 in mm) and (g/L) = 0.16𝑥 - 0.06 (where 𝑥 = TEG® 6s CFF MA in mm). CONCLUSIONS The present study revealed acceptable agreement between four different assays measuring functional fibrinogen, with current- and previous-generation ROTEM® machines (Sigma, Delta) performing similarly measuring functional fibrinogen via FIBTEM assay. This suggests that haemostatic resuscitation algorithms designed for the ROTEM® Delta can be applied to the ROTEM® Sigma to guide fibrinogen replacement.
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Affiliation(s)
- Travis Auty
- Intensive Care Unit, Rockhampton Hospital, Rockhampton, Queensland, Australia
| | - James McCullough
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Griffith University, Gold Coast, Queensland, Australia
| | - Ian Hughes
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Office for Research Governance and Development, Gold Coast University Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Jonathon P Fanning
- University of Queensland, Brisbane, Queensland, Australia
- Intensive Care Unit, St Andrew's War Memorial Hospital, UnitingCare Health, Brisbane, Queensland, Australia
- Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Sarah Czuchwicki
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - James Winearls
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Griffith University, Gold Coast, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
- Intensive Care Unit, St Andrew's War Memorial Hospital, UnitingCare Health, Brisbane, Queensland, Australia
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2
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Forster EK, Hendel S, Mitra B. Detection of Acute Traumatic Coagulopathy by Viscoelastic Haemostatic Assays Compared to Standard Laboratory Tests: A Systematic Review. Transfus Med Hemother 2023; 50:334-347. [PMID: 37767279 PMCID: PMC10521251 DOI: 10.1159/000526217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 07/24/2022] [Indexed: 09/29/2023] Open
Abstract
Introduction The aim of this systematic review was to investigate whether viscoelastic haemostatic assays (VHAs) offer comparative diagnostic ability of acute traumatic coagulopathy (ATC) compared to the standard laboratory coagulation tests (SLCT). ATC is a complication of major trauma characterized by dysfunctional blood clotting, leading to an increased bleeding risk. Additionally, we aimed to analyse the association of VHA with blood product use and health outcomes. Methods The search protocol was pre-published and completed on December 2, 2020, assessing manuscripts from 2000 until the present. We searched MEDLINE, Embase, Cochrane Central, BIOSIS, Emcare, CINAHL, and additional online resources and referenced lists. Included were manuscripts that quantitatively reported the detection of ATC using VHAs and SLCTs. A meta-analysis was undertaken including observational studies that reported on patients with injuries to all body regions and results analysed using a random-effects model and reported using pooled odds ratio with 95% confidence intervals (CI). Results There were 14 observational studies and one randomized control trial involving 2,715 participants that satisfied inclusion criteria. We observed significant heterogeneity in the definitions of ATC, study design, setting, and patient population. Among observational studies that reported on patients with injuries to all body regions, VHAs were associated with higher odds of diagnosing ATC compared to SLCT (pooled OR 2.4; 95% CI: 1.4-4.1). There was inadequate evidence to suggest VHAs were associated with reduced blood product usage or lower mortality. Conclusion VHAs detected more patients with ATC compared to SLCTs. However, the clinical significance and applicability of this finding remains unknown as translation to management was not adequately reported.
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Affiliation(s)
- Ellen K. Forster
- Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Monash University, Central Clinical School, Melbourne, Victoria, Australia
| | - Simon Hendel
- National Trauma Research Institute, Monash University, Central Clinical School, Melbourne, Victoria, Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University and Alfred Health, Melbourne, Victoria, Australia
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, Monash University, Central Clinical School, Melbourne, Victoria, Australia
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3
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Liu LY, Nathan L, Sheen JJ, Goffman D. Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage. Int J Womens Health 2023; 15:905-926. [PMID: 37283995 PMCID: PMC10241213 DOI: 10.2147/ijwh.s366675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/03/2023] [Indexed: 06/08/2023] Open
Abstract
Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.
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Affiliation(s)
- Lilly Y Liu
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Lisa Nathan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jean-Ju Sheen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Dena Goffman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
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4
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Duclos G, Fleury M, Grosdidier C, Lakbar I, Antonini F, Lassale B, Arbelot C, Albaladejo P, Zieleskiewicz L, Leone M. Blood coagulation test abnormalities in trauma patients detected by sonorheometry: a retrospective cohort study. Res Pract Thromb Haemost 2023; 7:100163. [PMID: 37251493 PMCID: PMC10208882 DOI: 10.1016/j.rpth.2023.100163] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 03/17/2023] [Accepted: 04/03/2023] [Indexed: 05/31/2023] Open
Abstract
Background Traumatic hemorrhage guidelines include point-of-care viscoelastic tests as a standard of care. Quantra (Hemosonics) is a device based on sonic estimation of elasticity via resonance (SEER) sonorheometry to assess whole blood clot formation. Objectives Our study aimed to assess the ability of an early SEER evaluation to detect blood coagulation test abnormalities in trauma patients. Methods We conducted an observational retrospective cohort study with data collected at hospital admission of consecutive multiple trauma patients from September 2020 to February 2022 at a regional level 1 trauma center. We performed a receiving operator characteristic curve analysis to determine the ability of the SEER device to detect blood coagulation test abnormalities. Four values on the SEER device were analyzed: clot formation time, clot stiffness (CS), platelet contribution to CS, and fibrinogen contribution to CS. Results A total of 156 trauma patients were analyzed. The clot formation time value predicted an activated partial thromboplastin time ratio of >1.5 with an area under the curve (AUC) of 0.93 (95% CI, 0.86-0.99). The AUC of the CS value in detecting an international normalized ratio of prothrombin time of >1.5 was 0.87 (95% CI, 0.79-0.95). The AUC of fibrinogen contribution to CS to detect a fibrinogen concentration of <1.5 g/L was 0.87 (95% CI, 0.80-0.94). The AUC of platelet contribution to CS to detect a platelet concentration of <50 G/L was 0.99 (95% CI, 0.99-1.00). Conclusion Our results suggest that the SEER device may be useful for the detection of blood coagulation test abnormalities at trauma admission.
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Affiliation(s)
- Gary Duclos
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Marie Fleury
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Charlotte Grosdidier
- Service of Medical Biology, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Ines Lakbar
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - François Antonini
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Bernard Lassale
- French Establishment for Blood, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Charlotte Arbelot
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Pierre Albaladejo
- Department of Anesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Laurent Zieleskiewicz
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
| | - Marc Leone
- Service of Anesthesia and Intensive Care, Hôpital Nord, Aix-Marseille Université, Marseille, France
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Eskildsen MPR, Kalliokoski O, Boennelycke M, Lundquist R, Settnes A, Loekkegaard E. An autologous blood-derived patch as a hemostatic agent: evidence from thromboelastography experiments and a porcine liver punch biopsy model. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2023; 34:20. [PMID: 37074487 PMCID: PMC10115690 DOI: 10.1007/s10856-023-06726-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 04/03/2023] [Indexed: 05/03/2023]
Abstract
Perioperative bleeding is a common complication in surgeries that increases morbidity, risk of mortality, and leads to increased socioeconomic costs. In this study we investigated a blood-derived autologous combined leukocyte, platelet, and fibrin patch as a new means of activating coagulation and maintaining hemostasis in a surgical setting. We evaluated the effects of an extract derived from the patch on the clotting of human blood in vitro, using thromboelastography (TEG). The autologous blood-derived patch activated hemostasis, seen as a reduced mean activation time compared to both non-activated controls, kaolin-activated samples, and fibrinogen/thrombin-patch-activated samples. The accelerated clotting was reproducible and did not compromise the quality or stability of the resulting blood clot. We also evaluated the patch in vivo in a porcine liver punch biopsy model. In this surgical model we saw 100% effective hemostasis and a significant reduction of the time-to-hemostasis, when compared to controls. These results were comparable to the hemostatic properties of a commercially available, xenogeneic fibrinogen/thrombin patch. Our findings suggest clinical potential for the autologous blood-derived patch as a hemostatic agent.
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Affiliation(s)
- Morten P R Eskildsen
- Department of Obstetrics and Gynecology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
- Department of Experimental Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Otto Kalliokoski
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Experimental Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marie Boennelycke
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Pathology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | | | - Annette Settnes
- Department of Obstetrics and Gynecology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ellen Loekkegaard
- Department of Obstetrics and Gynecology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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6
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Neidert LE, Morgan CG, Hathaway EN, Hemond PJ, Tiller MM, Cardin S, Glaser JJ. Effects of hemodilution on coagulation function during prolonged hypotensive resuscitation in a porcine model of severe hemorrhagic shock. Trauma Surg Acute Care Open 2023; 8:e001052. [PMID: 37213865 PMCID: PMC10193089 DOI: 10.1136/tsaco-2022-001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/27/2023] [Indexed: 05/23/2023] Open
Abstract
Background Although hemorrhage remains the leading cause of survivable death in casualties, modern conflicts are becoming more austere limiting available resources to include resuscitation products. With limited resources also comes prolonged evacuation time, leaving suboptimal prehospital field care conditions. When blood products are limited or unavailable, crystalloid becomes the resuscitation fluid of choice. However, there is concern of continuous crystalloid infusion during a prolonged period to achieve hemodynamic stability for a patient. This study evaluates the effect of hemodilution from a 6-hour prehospital hypotensive phase on coagulation in a porcine model of severe hemorrhagic shock. Methods Adult male swine (n=5/group) were randomized into three experimental groups. Non-shock (NS)/normotensive did not undergo injury and were controls. NS/permissive hypotensive (PH) was bled to the PH target of systolic blood pressure (SBP) 85±5 mm Hg for 6 hours of prolonged field care (PFC) with SBP maintained via crystalloid, then recovered. Experimental group underwent controlled hemorrhage to mean arterial pressure 30 mm Hg until decompensation (Decomp/PH), followed by PH resuscitation with crystalloid for 6 hours. Hemorrhaged animals were then resuscitated with whole blood and recovered. Blood samples were collected at certain time points for analysis of complete blood counts, coagulation function, and inflammation. Results Throughout the 6-hour PFC, hematocrit, hemoglobin, and platelets showed significant decreases over time in the Decomp/PH group, indicating hemodilution, compared with the other groups. However, this was corrected with whole blood resuscitation. Despite the appearance of hemodilution, coagulation and perfusion parameters were not severely compromised. Conclusions Although significant hemodilution occurred, there was minimal impact on coagulation and endothelial function. This suggests that it is possible to maintain the SBP target to preserve perfusion of vital organs at a hemodilution threshold in resource-constrained environments. Future studies should address therapeutics that can mitigate potential hemodilutional effects such as lack of fibrinogen or platelets. Level of evidence Not applicable-Basic Animal Research.
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Affiliation(s)
- Leslie E Neidert
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Clifford G Morgan
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Emily N Hathaway
- Division of Trauma, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas, USA
| | - Peter J Hemond
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Michael M Tiller
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
- Division of Trauma, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas, USA
| | - Sylvain Cardin
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Jacob J Glaser
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
- Trauma and Acute Care Surgery, Providence Regional Medical Center Everett, Everett, Washington, USA
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7
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Bunch CM, Chang E, Moore EE, Moore HB, Kwaan HC, Miller JB, Al-Fadhl MD, Thomas AV, Zackariya N, Patel SS, Zackariya S, Haidar S, Patel B, McCurdy MT, Thomas SG, Zimmer D, Fulkerson D, Kim PY, Walsh MR, Hake D, Kedar A, Aboukhaled M, Walsh MM. SHock-INduced Endotheliopathy (SHINE): A mechanistic justification for viscoelastography-guided resuscitation of traumatic and non-traumatic shock. Front Physiol 2023; 14:1094845. [PMID: 36923287 PMCID: PMC10009294 DOI: 10.3389/fphys.2023.1094845] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/07/2023] [Indexed: 03/03/2023] Open
Abstract
Irrespective of the reason for hypoperfusion, hypocoagulable and/or hyperfibrinolytic hemostatic aberrancies afflict up to one-quarter of critically ill patients in shock. Intensivists and traumatologists have embraced the concept of SHock-INduced Endotheliopathy (SHINE) as a foundational derangement in progressive shock wherein sympatho-adrenal activation may cause systemic endothelial injury. The pro-thrombotic endothelium lends to micro-thrombosis, enacting a cycle of worsening perfusion and increasing catecholamines, endothelial injury, de-endothelialization, and multiple organ failure. The hypocoagulable/hyperfibrinolytic hemostatic phenotype is thought to be driven by endothelial release of anti-thrombogenic mediators to the bloodstream and perivascular sympathetic nerve release of tissue plasminogen activator directly into the microvasculature. In the shock state, this hemostatic phenotype may be a counterbalancing, yet maladaptive, attempt to restore blood flow against a systemically pro-thrombotic endothelium and increased blood viscosity. We therefore review endothelial physiology with emphasis on glycocalyx function, unique biomarkers, and coagulofibrinolytic mediators, setting the stage for understanding the pathophysiology and hemostatic phenotypes of SHINE in various etiologies of shock. We propose that the hyperfibrinolytic phenotype is exemplified in progressive shock whether related to trauma-induced coagulopathy, sepsis-induced coagulopathy, or post-cardiac arrest syndrome-associated coagulopathy. Regardless of the initial insult, SHINE appears to be a catecholamine-driven entity which early in the disease course may manifest as hyper- or hypocoagulopathic and hyper- or hypofibrinolytic hemostatic imbalance. Moreover, these hemostatic derangements may rapidly evolve along the thrombohemorrhagic spectrum depending on the etiology, timing, and methods of resuscitation. Given the intricate hemochemical makeup and changes during these shock states, macroscopic whole blood tests of coagulative kinetics and clot strength serve as clinically useful and simple means for hemostasis phenotyping. We suggest that viscoelastic hemostatic assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are currently the most applicable clinical tools for assaying global hemostatic function-including fibrinolysis-to enable dynamic resuscitation with blood products and hemostatic adjuncts for those patients with thrombotic and/or hemorrhagic complications in shock states.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Eric Chang
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States
| | - Hunter B Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States.,Department of Transplant Surgery, Denver Health and University of Colorado Health Sciences Center, Denver, CO, United States
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Mahmoud D Al-Fadhl
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Anthony V Thomas
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Nuha Zackariya
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Shivani S Patel
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Sufyan Zackariya
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Saadeddine Haidar
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Bhavesh Patel
- Division of Critical Care, Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Scott G Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Donald Zimmer
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Daniel Fulkerson
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | - Daniel Hake
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Archana Kedar
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Michael Aboukhaled
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Mark M Walsh
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States.,Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
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8
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Gebekova ZA, Ivanov II, Asambayeva A, Skripka AI, Sokolova AA, Napalkov DA, Vuimo TA. Thrombodynamics Test in Assessing the Risk of Thrombus Formation in Patients with Atrial Fibrillation Taking Direct Oral Anticoagulants. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-09-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Aim. To evaluate thrombus characteristics in patients with atrial fibrillation (AF) taking different direct oral anticoagulants (DOACs) using Thrombodynamics test.Materials and methods. Thrombodynamics test was performed in 100 patients with paroxysmal and permanent forms of AF taking different DOACs, dose choice was done in accordance with the instructions for drugs use. For analysis samples of fresh citrated platelet-free plasma were taken just before regular DOACs dose intake (trough concentration). Statistical data processing was carried out using R software packages.Results. All patients had no history of thrombosis or bleeding before inclusion in this study. All parameters of Thrombodynamics test taken at residual concentration of DOACs were in general within reference values, that is in the area of normal coagulation: spatial clot growth rate (V) – 26.56 (25.0; 29.2) μm/min, the time to the start of clot growth (Tlag) – 1.05 (0.85; 1.27) min, initial spatial clot growth rate (Vi) – 44.3±7.7 μm/min, stationary spatial clot growth rate (Vst) – 26.5 (24.9; 28.4) μm/min, clot size (CS) – 999.7 (912.9; 1084.7) μm, clot density (D) – 22883.1±3199.9 arb. units. D was appeared to be higher in women [22947.7 (21477.5; 22947.7) vs men [22124.8 (19722.8; 22124.8), p=0.035] and Tlag was significantly higher in patients with chronic heart failure [1.2 (1.0; 1.2) vs 1.0 (0.8; 1.0), p=0.008]. A correlation was found between level of creatinine and Tlag parameter, glomerular filtration rate (GFR) and clot density. With an increase in the level of creatinine in the blood and a decrease in GFR, respectively, there was an increase in Tlag parameter (p-value 0.038); with an increase in GFR, clot density decrease (p-value 0.005).Conclusion. All parameters of Thrombodynamics test on residual concentration of DOACs were within reference values that indicated optimal anticoagulant effect of all DOACs. The obtained data of normal coagulation at the residual concentration of the anticoagulant are consistent with the previously obtained data on the safety and effectiveness of DOACs using other methods. Further studies with clinical end points are needed to assess the clinical value of this method.
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Affiliation(s)
- Z. A. Gebekova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - I. I. Ivanov
- Pirogov Russian National Research Medical University
| | - A. Asambayeva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. I. Skripka
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. A. Sokolova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - D. A. Napalkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - T. A. Vuimo
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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9
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Niemann M, Otto E, Eder C, Youssef Y, Kaufner L, Märdian S. Coagulopathy management of multiple injured patients - a comprehensive literature review of the European guideline 2019. EFORT Open Rev 2022; 7:710-726. [PMID: 36287131 PMCID: PMC9619392 DOI: 10.1530/eor-22-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The European guideline on the management of trauma-induced major bleeding and coagulopathy summarises the most relevant recommendations for trauma coagulopathy management. The management of trauma-induced major bleeding should interdisciplinary follow algorithms which distinguish between life-threatening and non-life-threatening bleeding. Point-of-care viscoelastic methods (VEM) assist target-controlled haemostatic treatment. Neither conventional coagulation assays nor VEM should delay treatment in life-threatening trauma-induced bleeding. Adjustments may be rational due to local circumstances, including the availability of blood products, pharmaceuticals, and employees.
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Affiliation(s)
- Marcel Niemann
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany,Correspondence should be addressed to M Niemann;
| | - Ellen Otto
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,Julius Wolff Institute for Biomechanics and Musculoskeletal Regeneration, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Eder
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Yasmin Youssef
- Department of Orthopaedics, Trauma Surgery and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Lutz Kaufner
- Charité – Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sven Märdian
- Charité – Universitätsmedizin Berlin, Center for Musculoskeletal Surgery, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Mamczak CN, Speybroeck J, Stillson JE, Dynako J, Piscoya A, Peck EE, Aboukhaled M, Cancel E, McDonald M, Garcia D, Lovejoy J, Lubin S, Stanton R, Kutcher ME. Viscoelastic Hemostatic Assays for Orthopedic Trauma and Elective Procedures. J Clin Med 2022; 11:jcm11144029. [PMID: 35887803 PMCID: PMC9323142 DOI: 10.3390/jcm11144029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
The application of viscoelastic hemostatic assays (VHAs) (e.g., thromboelastography (TEG) and rotational thromboelastometry (ROTEM)) in orthopedics is in its relative infancy when compared with other surgical fields. Fortunately, several recent studies describe the emerging use of VHAs to quickly and reliably analyze the real-time coagulation and fibrinolytic status in both orthopedic trauma and elective orthopedic surgery. Trauma-induced coagulopathy—a spectrum of abnormal coagulation phenotypes including clotting factor depletion, inadequate thrombin generation, platelet dysfunction, and dysregulated fibrinolysis—remains a potentially fatal complication in severely injured and/or hemorrhaging patients whose timely diagnosis and management are aided by the use of VHAs. Furthermore, VHAs are an invaluable compliment to common coagulation tests by facilitating the detection of hypercoagulable states commonly associated with orthopedic injury and postoperative status. The use of VHAs to identify hypercoagulability allows for an accurate venous thromboembolism (VTE) risk assessment and monitoring of VTE prophylaxis. Until now, the data have been insufficient to permit an individualized approach with regard to dosing and duration for VTE thromboprophylaxis. By incorporating VHAs into routine practice, orthopedic surgeons will be better equipped to diagnose and treat the complete spectrum of coagulation abnormalities faced by orthopedic patients. This work serves as an educational primer and up-to-date review of the current literature on the use of VHAs in orthopedic surgery.
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Affiliation(s)
- Christiaan N. Mamczak
- Department of Orthopaedic Trauma, Florida Orthopaedic Institute, St. Petersburg, FL 33701, USA;
| | - Jacob Speybroeck
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA;
| | - John E. Stillson
- Department of Family Medicine, John Peter Smith Hospital, Fort Worth, TX 76104, USA
- Correspondence:
| | - Joseph Dynako
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Andres Piscoya
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA;
| | - Ethan E. Peck
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Michael Aboukhaled
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Emily Cancel
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Michael McDonald
- Department of Graduate Medical Education, Naval Medical Readiness and Training Command, Portsmouth, VA 23708, USA;
| | - Diego Garcia
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - John Lovejoy
- Department of Orthopaedic Surgery, University of Florida Health Jacksonville, Jacksonville, FL 32209, USA;
| | - Stephanie Lubin
- Department of Orthopaedic Surgery, Hôpital Sacré Coeur, Milot 1230, Haiti;
| | - Robert Stanton
- Department of Pediatric Orthopaedics, Nemours Children’s Health-Florida, Orlando, FL 32827, USA;
| | - Matthew E. Kutcher
- Departments of Surgery and Emergency Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA;
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11
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Bergman ZR, Robbins AJ, Alwan FS, Bellin MD, Kirchner VA, Pruett TL, Mulier KE, Boucher AA, Lusczek ER, Beilman GJ. Perioperative Coagulation Changes in Total Pancreatectomy and Islet Autotransplantation. Pancreas 2022; 51:671-677. [PMID: 36099513 PMCID: PMC9547836 DOI: 10.1097/mpa.0000000000002085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Thrombotic complications after total pancreatectomy with islet autotransplantation (TPIAT) are common. However, the systemic changes to coagulation in the perioperative period have not been well studied. Our objective was to evaluate the derangements in coagulation in the perioperative period for this procedure. METHODS This was a prospective observational study of patients undergoing elective TPIAT for chronic pancreatitis. Multiple methods of evaluating coagulation, including 2 viscoelastic assays and standard laboratory assays were obtained at defined intraoperative and postoperative intervals. RESULTS Fifteen patients were enrolled. Laboratory values demonstrated initial intraoperative hypercoagulability before significant systemic anticoagulation after islet infusion with heparin. Hypercoagulability is again seen at postoperative days 3 and 7. Subgroup analysis did not identify any major coagulation parameters associated with portal vein thrombosis formation. CONCLUSIONS Apart from the immediate period after islet cell and heparin infusion, patients undergoing TPIAT are generally hypercoagulable leading to a high rate of thrombotic complications. Portal vein thrombosis development had minimal association with systemic derangements in coagulation as it is likely driven by localized inflammation at the time of islet cell infusion. This study may provide the groundwork for future studies to identify improvements in thrombotic complications.
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Affiliation(s)
| | | | | | | | | | | | | | - Alex A Boucher
- Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, MN
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12
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Premkumar M, Kulkarni AV, Kajal K, Divyaveer S. Principles, Interpretation, and Evidence-Based Role of Viscoelastic Point-of-Care Coagulation Assays in Cirrhosis and Liver Failure. J Clin Exp Hepatol 2022; 12:533-543. [PMID: 35535095 PMCID: PMC9077199 DOI: 10.1016/j.jceh.2021.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/02/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Aims Standard coagulation tests such as prothrombin time, activated partial thromboplastin time, and international normalized ratio are determined by liver-synthesized coagulation factors. Despite an increased international normalized ratio, patients with cirrhosis are in a "rebalanced" state of hemostasis as the concomitant effect of reduced protein C, protein S, and thrombomodulin is not evaluated in standard coagulation tests. The cell-based model of hemostasis indicates additional mechanisms such as systemic inflammation, sepsis, and organ failures tip the delicate coagulation balance to an anticoagulant type in acute-on-chronic liver failure. In acute liver failure, thrombin generation and platelet function remain intact despite a marked prolongation in prothrombin time. We aimed to explain the principles, application, and utility of viscoelastic tests such as thromboelastography, rotational thromboelastometry, and Sonoclot. Methods We reviewed the available literature from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trial with the search terms 'coagulation', 'cirrhosis', 'acute-on-chronic liver failure', 'thromboelastography', 'thromboelastometry' and 'sonoclot' for cross sectional studies, cohort studies and randomized trials. Results The point-of-care viscoelastic tests provide actionable targets for correcting the coagulation defect in a patient with bleeding and provide evidence-based algorithms for use in liver disease. A limitation of these tests is the inability to assess vessel injury and endothelial elements. Conclusion Global coagulation tests provide a comprehensive estimate of coagulation in vitro; however, their use has only been validated in the setting of liver transplantation. Newer guidelines for hemostatic resuscitation are now accepting these POC tests, but additional data are required to validate their use as standard of care.
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Key Words
- ACLF, acute-on-chronic liver failure
- ACT, activated clotting time
- ALF, acute liver failure
- CR, clot rate
- INR, international normalized ratio
- MA, maximum amplitude
- R, reaction time
- ROTEM
- ROTEM, rotational thromboelastometry
- SCT, standard coagulation tests
- TEG, thromboelastography
- VWF, von Willebrand factor
- aPTT, activated partial thromboplastin time
- cirrhosis
- coagulation
- sonoclot
- thromboelastography
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anand V. Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Kamal Kajal
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Smita Divyaveer
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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13
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Qu D, Li W, Zhang S, Li R, Wang H, Chen B. Traumatic Brain Injury Is Associated With Both Hemorrhagic Stroke and Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Neurosci 2022; 16:814684. [PMID: 35221904 PMCID: PMC8867812 DOI: 10.3389/fnins.2022.814684] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background Traumatic brain injury (TBI) is considered a risk factor for the development of stroke (Hemorrhagic Stroke and Ischemic Stroke). We performed this systemic review and meta-analysis to determine the association of prior TBI with the subsequent diagnosis of stroke. Methods We systematically searched PubMed, EMBASE, and the Cochrane Library for cohort studies involving TBI patients who subsequently developed stroke. Study selection, data extraction, and quality assessment were performed by two separate researchers. Data were analyzed with random-effects models, and a secondary analysis stratified by the type of stroke was performed. Results Of the 741 identified studies, 6 studies were eligible for inclusion, with more than 2,200,000 participants. TBI predicted the occurrence of stroke in the random-effect model, with a relative risk of 2.14 (95% CI 1.97–2.32, P < 0.001). Furthermore, in the analysis of each type of stroke, TBI was associated with the incidence of ischemic stroke (RR 1.351 95% CI 1.212–1.506, P < 0.001), and TBI was associated with an even greater increase in the incidence of hemorrhagic stroke (RR 6.118 95% CI 5.265–7.108, P < 0.001). Conclusion Our meta-analysis showed that TBI was associated with a more than two-fold increase in the risk of stroke. However, owing to the high degree of heterogeneity, decisions should be made on a patient-by-patient basis. The occurrence of TBI is associated with the development of both hemorrhagic and ischemic stroke, and the risk of hemorrhagic stroke is much higher than that of ischemic stroke in TBI patients.
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Affiliation(s)
- Donghao Qu
- Department of Neurosurgery (Neurotrauma), The First Hospital of Jilin University, Changchun, China
| | - Wenchen Li
- Department of Neurosurgery (Neurotrauma), The First Hospital of Jilin University, Changchun, China
| | - Shuyan Zhang
- Department of Neurosurgery (Neurotrauma), The First Hospital of Jilin University, Changchun, China
| | - Ri Li
- Department of Library, The First Hospital of Jilin University, Changchun, China
| | - Haifeng Wang
- Department of Neurosurgery (Neurotrauma), The First Hospital of Jilin University, Changchun, China
- Haifeng Wang
| | - Bo Chen
- Department of Neurosurgery (Neurotrauma), The First Hospital of Jilin University, Changchun, China
- *Correspondence: Bo Chen
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14
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Viscoelastic Hemostatic Assays: A Primer on Legacy and New Generation Devices. J Clin Med 2022; 11:jcm11030860. [PMID: 35160311 PMCID: PMC8836477 DOI: 10.3390/jcm11030860] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 02/06/2023] Open
Abstract
Viscoelastic hemostatic assay (VHAs) are whole blood point-of-care tests that have become an essential method for assaying hemostatic competence in liver transplantation, cardiac surgery, and most recently, trauma surgery involving hemorrhagic shock. It has taken more than three-quarters of a century of research and clinical application for this technology to become mainstream in these three clinical areas. Within the last decade, the cup and pin legacy devices, such as thromboelastography (TEG® 5000) and rotational thromboelastometry (ROTEM® delta), have been supplanted not only by cartridge systems (TEG® 6S and ROTEM® sigma), but also by more portable point-of-care bedside testing iterations of these legacy devices (e.g., Sonoclot®, Quantra®, and ClotPro®). Here, the legacy and new generation VHAs are compared on the basis of their unique hemostatic parameters that define contributions of coagulation factors, fibrinogen/fibrin, platelets, and clot lysis as related to the lifespan of a clot. In conclusion, we offer a brief discussion on the meteoric adoption of VHAs across the medical and surgical specialties to address COVID-19-associated coagulopathy.
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15
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Lantry JH, Mason P, Logsdon MG, Bunch CM, Peck EE, Moore EE, Moore HB, Neal MD, Thomas SG, Khan RZ, Gillespie L, Florance C, Korzan J, Preuss FR, Mason D, Saleh T, Marsee MK, Vande Lune S, Ayoub Q, Fries D, Walsh MM. Hemorrhagic Resuscitation Guided by Viscoelastography in Far-Forward Combat and Austere Civilian Environments: Goal-Directed Whole-Blood and Blood-Component Therapy Far from the Trauma Center. J Clin Med 2022; 11:356. [PMID: 35054050 PMCID: PMC8778082 DOI: 10.3390/jcm11020356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 12/31/2021] [Accepted: 01/10/2022] [Indexed: 12/18/2022] Open
Abstract
Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued resuscitation with fixed ratios of blood products, the debate about the optimal resuscitation strategy-especially in austere or challenging environments-is by no means settled. In this narrative review, we give a brief history of military resuscitation and how whole blood became the mainstay of initial resuscitation. We then outline the principles of viscoelastic hemostatic assays as well as their adoption for providing goal-directed blood-component therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival.
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Affiliation(s)
- James H. Lantry
- Department of Medicine Critical Care Services, Inova Fairfax Medical Campus, Falls Church, VA 22042, USA;
| | - Phillip Mason
- Department of Critical Care Medicine, San Antonio Military Medical Center, Fort Sam Houston, San Antonio, TX 78234, USA;
| | - Matthew G. Logsdon
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, Notre Dame, IN 46617, USA; (M.G.L.); (C.M.B.)
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Connor M. Bunch
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, Notre Dame, IN 46617, USA; (M.G.L.); (C.M.B.)
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Ethan E. Peck
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Ernest E. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health and University of Colorado Health Sciences Center, Denver, CO 80204, USA; (E.E.M.); (H.B.M.)
| | - Hunter B. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health and University of Colorado Health Sciences Center, Denver, CO 80204, USA; (E.E.M.); (H.B.M.)
| | - Matthew D. Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Scott G. Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, Beacon Health System, South Bend, IN 46601, USA;
| | - Rashid Z. Khan
- Department of Hematology, Michiana Hematology Oncology, Mishawaka, IN 46545, USA;
| | - Laura Gillespie
- Department of Quality Assurance and Performance Improvement, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Charles Florance
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Josh Korzan
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
| | - Fletcher R. Preuss
- Department of Orthopaedic Surgery, UCLA Santa Monica Medical Center and Orthopaedic Institute, Santa Monica, CA 90404, USA;
| | - Dan Mason
- Department of Medical Science and Devices, Haemonetics Corporation, Braintree, MA 02184, USA;
| | - Tarek Saleh
- Department of Critical Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA;
| | - Mathew K. Marsee
- Department of Graduate Medical Education, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA;
| | - Stefani Vande Lune
- Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA;
| | | | - Dietmar Fries
- Department of Surgical and General Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Mark M. Walsh
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, Notre Dame, IN 46617, USA; (M.G.L.); (C.M.B.)
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (C.F.); (J.K.)
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16
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Oh MW, Valencia J, Moon TS. Anesthetic Considerations for the Trauma Patient with Obesity. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00508-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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17
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Ishikawa T, Nakajima Y, Omae T, Ogiwara K, Nogami K. Comprehensive coagulation and fibrinolytic potential in the acute phase of pediatric patients with idiopathic nephrotic syndrome evaluated by whole blood-based rotational thromboelastometry. Pediatr Nephrol 2022; 37:1605-1614. [PMID: 34997323 PMCID: PMC8741554 DOI: 10.1007/s00467-021-05366-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/09/2021] [Accepted: 11/09/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Venous thromboembolism is a rare, serious complication of idiopathic nephrotic syndrome (INS) in childhood. The mechanisms responsible for the hypercoagulable state in the acute phase of INS are poorly understood, however. This study aimed to assess overall coagulation and fibrinolytic function in pediatric patients with INS. METHODS Global coagulation and fibrinolysis were examined in whole blood samples from 22 children with initial onset INS (initial-group), 22 children with relapsed INS (relapse-group), and 15 control pediatric patients using rotational thromboelastometry (ROTEM®). In the initial-group, blood samples were obtained before (week 0) and 1-4 weeks after initiation of corticosteroid therapy. EXTEM and FIBTEM were used to assess coagulation and fibrinolysis, respectively. Clot time (CT), clot formation time (CFT), maximum clot firmness (MCF), and α-angle were determined as coagulation parameters, and lysis index at 30 and 60 min (LI30 and LI60, respectively) were assessed as fibrinolytic parameters. RESULTS CT was significantly shortened, and MCF and α-angle were significantly greater than controls at week 0 and week 1 both in the initial-group and the relapse-group. MCF correlated with serum albumin (r = 0.70, p < 0.001) and fibrinogen level (r = 0.68, p < 0.001). The fibrinolytic parameters (LI30 and LI60) in the initial-group were stable and higher than those in controls at all time points (p < 0.01). CONCLUSIONS We have shown that the hypofibrinolytic defect did not improve with effective NS treatment at the early 4-week time-point. Additionally, a likely pre-thrombotic state was evident in the period before initial onset and 1 week after corticosteroid therapy in pediatric INS.
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Affiliation(s)
- Tomoaki Ishikawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan ,Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara Japan
| | - Takashi Omae
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522 Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
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18
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Xuan J, Wang J, Wei B. Diagnostic Value of Thromboelastography (TEG) for the Diagnosis of Death in Infected Patients. Clin Appl Thromb Hemost 2021; 27:10760296211047231. [PMID: 34657478 PMCID: PMC8527583 DOI: 10.1177/10760296211047231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In this study, we want to investigate the clinical value of each index of thromboelastography (TEG) on the prognosis of infected patients.The clinical baseline data and TEG test results of 431 infected patients in our hospital's emergency department between January 2018 and December 2018 were selected. And the patients were divided into death and survival groups to analyze the predictive value of each index of TEG and the joint model on the death of infected patients.In the correlation study of C-reactive protein (CRP) and procalcitonin (PCT) with each TEG parameter, CRP was positively correlated with maximum amplitude (MA, r = 0.145, P = .003) and elasticity constants (E, r = 0.098, P = .043), respectively. PCT was positively correlated with coagulation reaction time (R, r = 0.124, P = .010) and time to MA (TMA) (r = 0.165, P = .001), respectively; PCT was negatively correlated with α-Angle (r = 0.124, P = .010) and coagulation index (CI, r = -0.108, P = .026), respectively. Multifactorial regression analysis showed that granulocytes, thrombocytes, platelet distribution width (PDW), and infection site were independent influences on infected patients' death. Diagnostic data showed that all eight TEG indicators had good specificity for predicting death, but all had poor sensitivity; thrombodynamic potential index (TPI) had the best diagnostic value (area under the curve, AUC = 0.609, P = .002). The eight-indicator modeling of TEG showed that the TEG model combined with PCT and CRP, respectively, had lower diagnostic efficacy than PCT (AUC = 0.756, P < .001); however, TEG had better specificity (82.73%) when diagnosed independently.The granulocytes, thrombocytes, PDW, and infection site are independent influencing factors of death in infected patients. Each index of TEG has better specificity in the diagnosis of death in infected patients.
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Affiliation(s)
- Jingchao Xuan
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, & Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Capital Medical University, Beijing, China
| | - Junyu Wang
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, & Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Capital Medical University, Beijing, China
| | - Bing Wei
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, & Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Capital Medical University, Beijing, China
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Use of Thromboelastography in the Evaluation and Management of Patients With Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Crit Care Explor 2021; 3:e0526. [PMID: 34549189 PMCID: PMC8443808 DOI: 10.1097/cce.0000000000000526] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Supplemental Digital Content is available in the text. Traumatic brain injury is associated with coagulopathy that increases mortality risk. Viscoelastic hemostatic assays such as thromboelastography (Haemonetics SA, Signy, Switzerland) provide rapid coagulopathy assessment and may be particularly useful for goal-directed treatment of traumatic brain injury patients. We conducted a systematic review to assess thromboelastography in the evaluation and management of coagulopathy in traumatic brain injury patients.
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20
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Cannata G, Mariotti Zani E, Argentiero A, Caminiti C, Perrone S, Esposito S. TEG ® and ROTEM ® Traces: Clinical Applications of Viscoelastic Coagulation Monitoring in Neonatal Intensive Care Unit. Diagnostics (Basel) 2021; 11:diagnostics11091642. [PMID: 34573982 PMCID: PMC8465234 DOI: 10.3390/diagnostics11091642] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/28/2021] [Accepted: 09/04/2021] [Indexed: 12/14/2022] Open
Abstract
The concentration of the majority of hemostatic proteins differs considerably in early life, especially in neonates compared to adulthood. Knowledge of the concept of developmental hemostasis is an essential prerequisite for the proper interpretation of conventional coagulation tests (CCT) and is critical to ensure the optimal diagnosis and treatment of hemorrhagic and thrombotic diseases in neonatal age. Viscoelastic tests (VETs) provide a point-of-care, real-time, global, and dynamic assessment of the mechanical properties of the coagulation system with the examination of both cellular and plasma protein contributions to the initiation, formation, and lysis of clots. In this work, we provide a narrative review of the basic principles of VETs and summarize current evidence regarding the two most studied point-of-care VETs, thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®), in the field of neonatal care. A literature analysis shows that viscoelastic hemostatic monitoring appears to be a useful additive technique to CCT, allowing targeted therapy to be delivered quickly. These tools may allow researchers to determine the neonatal coagulation profile and detect neonatal patients at risk for postoperative bleeding, coagulation abnormalities in neonatal sepsis, and other bleeding events in a timely manner, guiding transfusion therapies using the goal-oriented transfusion algorithm. However, diagnosis and treatment algorithms incorporating VETs for neonatal patients in a variety of clinical situations should be developed and applied to improve clinical outcomes. Further studies should be performed to make routinary diagnostic and therapeutic application possible for the neonatal population.
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Affiliation(s)
- Giulia Cannata
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Elena Mariotti Zani
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Serafina Perrone
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
- Correspondence: ; Tel.: +39-0521-903524
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21
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Ilich A, Kumar V, Ferrara MJ, Henderson MW, Noubouossie DF, Jenkins DH, Kozar RA, Park MS, Key NS. Euglobulin clot lysis time reveals a high frequency of fibrinolytic activation in trauma. Thromb Res 2021; 204:22-28. [PMID: 34111811 DOI: 10.1016/j.thromres.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 05/07/2021] [Accepted: 05/24/2021] [Indexed: 11/30/2022]
Abstract
Activation of the fibrinolytic system plays a central role in the host response to trauma. There is significant heterogeneity in the degree of fibrinolysis activation at baseline that is usually assessed by whole blood thromboelastography (TEG). Few studies have focused on plasma markers of fibrinolysis that could add novel insights into the frequency and mechanisms of fibrinolytic activation in trauma. Global fibrinolysis in plasma was assessed using a modified euglobulin clot lysis time (ECLT) assay in 171 major trauma patients and compared to commonly assessed analytes of fibrinolysis. The median ECLT in trauma patients was significantly shorter at 8.5 h (IQR, 1.3-19.5) compared to 19.9 h (9.8-22.6) in healthy controls (p < 0.0001). ECLT values ≤2.5th percentile of the reference range were present in 83 (48.5%) of trauma patients, suggesting increased fibrinolytic activation. Shortened ECLT values were associated with elevated plasmin-antiplasmin (PAP) complexes and free tissue plasminogen activator (tPA) levels in plasma. Sixteen (9.2%) individuals met the primary outcome for massive transfusion, here defined as the critical administration threshold (CAT) of 3 units of packed red cells in any 60-minute period within the first 24 h. In a univariate screen, plasma biomarkers associated with CAT included D-dimer (p < 0.001), PAP (p < 0.05), free tPA (p < 0.05) and ECLT (p < 0.05). We conclude that fibrinolytic activation, measured by ECLT, is present in a high proportion of trauma patients at presentation. The shortened ECLT is partially driven by high tPA levels and is associated with high levels of circulating PAP complexes. Further studies are needed to determine whether ECLT is an independent predictor of trauma outcomes.
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Affiliation(s)
- Anton Ilich
- Division of Hematology, Department of Medicine and Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Vaibhav Kumar
- Division of Hematology, Department of Medicine and Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | | | - Michael W Henderson
- Division of Hematology, Department of Medicine and Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Denis F Noubouossie
- Division of Hematology, Department of Medicine and Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | | | - Rosemary A Kozar
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Myung S Park
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nigel S Key
- Division of Hematology, Department of Medicine and Blood Research Center, University of North Carolina, Chapel Hill, NC, USA.
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22
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Raimann FJ, Lindner ML, Martin C, Jennewein L, Lustenberger T, Piekarski F, Zacharowski K, Weber CF. Role of POC INR in the early stage of diagnosis of coagulopathy. Pract Lab Med 2021; 26:e00238. [PMID: 34095419 PMCID: PMC8167296 DOI: 10.1016/j.plabm.2021.e00238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 01/02/2023] Open
Abstract
Background Acute bleeding requires fast and targeted therapy. Therefore, knowledge of the patient's potential to form a clot is crucial. Point-of-care testing (POCT) provides fast and reliable information on coagulation. Structural circumstances, such as person-bound sample transport, can prolong the reporting of the results. The aim of the present study was to investigate the diagnostic quality and accuracy between POCT INR diagnostics and standard laboratory analysis (SLA) as well as the time advantage between a pneumatic tube and a personal-based transport system. Methods Two groups of haemorrhagic patients (EG: emergency department; OG: delivery room; each n = 12) were examined in the context of bleeding emergencies using POCT and SLA. Samples were transported via a pneumatic tube system or by a personal transport service. Results INR results between POCT and SLA showed a high and significant correlation (EG: p < 0.001; OG: p < 0.001). POCT results were reported significantly more quickly (EG: 1.1 vs. 39.6 min; OG: 2.0 vs. 75.0 min; p < 0.001) and required less time for analysis (EG: 0.3 vs. 24.0 min; OG: 0.5 vs. 45.0 min; p < 0.001) compared to SLA. The time for transportation with the pneumatic tube was significantly shorter (8.0 vs. 18.5 min; p < 0.001) than with the personal-based transport system. Conclusion The results of the present study suggest that POCT may be a suitable method for the emergency diagnosis and may be used as prognostic diagnostic elements in haemotherapy algorithms to initiate targeted haemotherapy at an early point in time.
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Affiliation(s)
- Florian J Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Marie-Louise Lindner
- Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Asklepios Clinics Hamburg, AK Wandsbek, Alphonsstraße 14, 22043, Hamburg, Germany
| | - Christoph Martin
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Lukas Jennewein
- Department of Gynecology and Obstetrics, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Florian Piekarski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Germany
| | - Christian F Weber
- Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Asklepios Clinics Hamburg, AK Wandsbek, Alphonsstraße 14, 22043, Hamburg, Germany
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23
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Premkumar M, Mehtani R, Divyaveer S, Kajal K, Kulkarni AV, Ahmed S, Kaur H, Kaur H, Dhiman R, Duseja A, De A. Clinical Validation of Global Coagulation Tests to Guide Blood Component Transfusions in Cirrhosis and ACLF. J Clin Transl Hepatol 2021; 9:210-219. [PMID: 34007803 PMCID: PMC8111111 DOI: 10.14218/jcth.2020.00121] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/06/2021] [Accepted: 01/20/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND AIMS Patients with cirrhosis and acute-on-chronic liver failure (ACLF) may have bleeding complications and need for invasive procedures. Point-of-care (POC) coagulation tests like thromboelastography (TEG) and Sonoclot may be better for guiding patient management than the standard coagulation tests (SCTs), like prothrombin time, platelet count and international normalized ratio. METHODS We prospectively compared and validated the POC tests and SCTs in 70 persons with ACLF and 72 persons with decompensated cirrhosis who had clinical bleeding and checked for episodes of re-bleeding and transfusion requirements. We assessed pre-procedure requirement of blood components when correction was done based on an SCT or POC strategy. RESULTS Episodes of bleeding were seen in 45% and 28% of ACLF and cirrhosis patient, respectively (p=0.036), with the major site of bleeding being gastrointestinal (31% and 16%, respectively). Platelet counts correlated with TEG-maximum amplitude in cirrhosis (p=0.045) and prothrombin time correlated positively with TEG-reaction (R) time (p=0.032), TEG-Clot kinetics (K) time (p=0.042), Son-activated clotting time (p=0.038) and negatively with clot rate (p=0.043) in ACLF, making these correctable target variables in POC transfusion algorithms. Of 223 procedures, transfusion of fresh frozen plasma and platelet concentrate was reduced by 25% (p=0.035) and 20.8% (p=0.045) by using a POC strategy in 76 patients. Correction of deranged Son-activated clotting time and TEG-reaction time was noted in 68% and 72% after 24 h of fresh frozen plasma transfusion in ACLF and 85% and 80% in cirrhosis, respectively. CONCLUSIONS Our study clinically validates that POC tests can better detect coagulation defects and transfusion thresholds in ACLF and cirrhosis, whereas use of conventional tests appear to be less suitable in patients with clinical bleeding. TRIAL REGISTRATION NCT04332484.
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Affiliation(s)
- Madhumita Premkumar
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Correspondence to: Madhumita Premkumar, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, Pin 160012, India. ORCID: https://orcid.org/0000-0003-2961-4148. Tel: +91-172-2754777, E-mail:
| | - Rohit Mehtani
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Smita Divyaveer
- Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamal Kajal
- Anesthesia, and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anand V. Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Syed Ahmed
- Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harmanpreet Kaur
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harpreet Kaur
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radhakrishna Dhiman
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Departments of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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24
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Cohen JF, Deeks JJ, Hooft L, Salameh JP, Korevaar DA, Gatsonis C, Hopewell S, Hunt HA, Hyde CJ, Leeflang MM, Macaskill P, McGrath TA, Moher D, Reitsma JB, Rutjes AWS, Takwoingi Y, Tonelli M, Whiting P, Willis BH, Thombs B, Bossuyt PM, McInnes MDF. Preferred reporting items for journal and conference abstracts of systematic reviews and meta-analyses of diagnostic test accuracy studies (PRISMA-DTA for Abstracts): checklist, explanation, and elaboration. BMJ 2021; 372:n265. [PMID: 33722791 PMCID: PMC7957862 DOI: 10.1136/bmj.n265] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
For many users of the biomedical literature, abstracts may be the only source of information about a study. Hence, abstracts should allow readers to evaluate the objectives, key design features, and main results of the study. Several evaluations have shown deficiencies in the reporting of journal and conference abstracts across study designs and research fields, including systematic reviews of diagnostic test accuracy studies. Incomplete reporting compromises the value of research to key stakeholders. The authors of this article have developed a 12 item checklist of preferred reporting items for journal and conference abstracts of systematic reviews and meta-analyses of diagnostic test accuracy studies (PRISMA-DTA for Abstracts). This article presents the checklist, examples of complete reporting, and explanations for each item of PRISMA-DTA for Abstracts.
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Affiliation(s)
- Jérémie F Cohen
- Department of Pediatrics and Inserm UMR 1153 (Centre of Research in Epidemiology and Statistics), Necker - Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Université de Paris, Paris, France
| | - Jonathan J Deeks
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, Utrecht University, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jean-Paul Salameh
- The Ottawa Hospital Research Institute Clinical Epidemiology Program, Ottawa, ON, Canada
- Faculty of Medicine, Queen's University, Kingston, ON, Canada
| | - Daniël A Korevaar
- Department of Respiratory Medicine, Academic Medical Centers, Amsterdam, Netherlands
| | | | - Sally Hopewell
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Harriet A Hunt
- Exeter Test Group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Chris J Hyde
- Exeter Test Group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Mariska M Leeflang
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Public Health, Academic Medical Centers, Amsterdam, Netherlands
| | | | - Trevor A McGrath
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada
| | - David Moher
- Centre for Journalology, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Johannes B Reitsma
- Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, Utrecht University, University Medical Center Utrecht, Utrecht, Netherlands
| | - Anne W S Rutjes
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Yemisi Takwoingi
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Penny Whiting
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Brian H Willis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Brett Thombs
- Lady Davis Institute of the Jewish General Hospital and Department of Psychiatry, McGill University, Montréal, QC, Canada
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Public Health, Academic Medical Centers, Amsterdam, Netherlands
| | - Matthew D F McInnes
- University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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25
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Kallioinen M, Valtonen M, Peltoniemi M, Hynninen VV, Saarikoski T, Söderholm O, Kauko T, Aittokallio J. Effects of implementing rotational thromboelastometry in cardiac surgery: A retrospective cohort study. J Perioper Pract 2021; 31:326-333. [PMID: 33427064 PMCID: PMC8406378 DOI: 10.1177/1750458920950662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Since 2013, rotational thromboelastometry has been available in our hospital to assess coagulopathy. The aim of the study was to retrospectively evaluate the effect of thromboelastometry testing in cardiac surgery patients. Altogether 177 patients from 2012 and 177 patients from 2014 were included. In 2014, the thromboelastometry testing was performed on 56 patients. The mean blood drainage volume decreased and the number of patients receiving platelets decreased between 2012 and 2014. In addition, the use of fresh frozen plasma units decreased, and the use of prothrombin complex concentrate increased in 2014. When studied separately, the patients with a thromboelastometry testing received platelets, fresh frozen plasma, fibrinogen and prothrombin complex concentrate more often, but smaller amounts of red blood cells. In conclusion, after implementing the thromboelastometry testing to the practice, the blood products were given more cautiously overall. The use of thromboelastometry testing was associated with increased possibility to receive coagulation product transfusions. However, it appears that thromboelastometry testing was mostly used to assist in management of major bleeding.
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Affiliation(s)
- Minna Kallioinen
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland.,Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland
| | - Mika Valtonen
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland.,Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland
| | - Marko Peltoniemi
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland.,Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland
| | - Ville-Veikko Hynninen
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland.,Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland
| | - Tuukka Saarikoski
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland.,Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland
| | - Oki Söderholm
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland.,Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland
| | - Tommi Kauko
- Auria Clinical Informatics, Turku University Hospital, Turku, Finland
| | - Jenni Aittokallio
- Division of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland.,Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland
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26
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Napolitano LM. Hemostatic defects in massive transfusion: an update and treatment recommendations. Expert Rev Hematol 2021; 14:219-239. [PMID: 33267678 DOI: 10.1080/17474086.2021.1858788] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Acute hemorrhage is a global healthcare issue, and remains the leading preventable cause of death in trauma. Acute severe hemorrhage can be related to traumatic, peripartum, gastrointestinal, and procedural causes. Hemostatic defects occur early in patients requiring massive transfusion. Early recognition and treatment of hemorrhage and hemostatic defects are required to save lives and to achieve optimal patient outcomes. AREAS COVERED This review discusses current evidence and trials aimed at identifying the optimal treatment for hemostatic defects in hemorrhage and massive transfusion. Literature search included PubMed and Embase. EXPERT OPINION Patients with acute hemorrhage requiring massive transfusion commonly develop coagulopathy due to specific hemostatic defects, and accurate diagnosis and prompt correction are required for definitive hemorrhage control. Damage control resuscitation and massive transfusion protocols are optimal initial treatment strategies, followed by goal-directed individualized resuscitation using real-time coagulation monitoring. Distinct phenotypes exist in trauma-induced coagulopathy, including 'Bleeding' or 'Thrombotic' phenotypes, and hyperfibrinolysis vs. fibrinolysis shutdown. The trauma 'lethal triad' (hypothermia, coagulopathy, acidosis) has been updated to the 'lethal diamond' (including hypocalcemia). A number of controversies in optimal management exist, including whole blood vs. component therapy, use of factor concentrates vs. blood products, optimal use of tranexamic acid, and prehospital plasma and tranexamic acid administration.
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Affiliation(s)
- Lena M Napolitano
- Department of Surgery, University of Michigan Health System, University Hospital, Ann Arbor, Michigan, USA
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27
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Baksaas-Aasen K, Gall LS, Stensballe J, Juffermans NP, Curry N, Maegele M, Brooks A, Rourke C, Gillespie S, Murphy J, Maroni R, Vulliamy P, Henriksen HH, Pedersen KH, Kolstadbraaten KM, Wirtz MR, Kleinveld DJB, Schäfer N, Chinna S, Davenport RA, Naess PA, Goslings JC, Eaglestone S, Stanworth S, Johansson PI, Gaarder C, Brohi K. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. Intensive Care Med 2021; 47:49-59. [PMID: 33048195 PMCID: PMC7550843 DOI: 10.1007/s00134-020-06266-1] [Citation(s) in RCA: 133] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 09/20/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Contemporary trauma resuscitation prioritizes control of bleeding and uses major haemorrhage protocols (MHPs) to prevent and treat coagulopathy. We aimed to determine whether augmenting MHPs with Viscoelastic Haemostatic Assays (VHA) would improve outcomes compared to Conventional Coagulation Tests (CCTs). METHODS This was a multi-centre, randomized controlled trial comparing outcomes in trauma patients who received empiric MHPs, augmented by either VHA or CCT-guided interventions. Primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of massive transfusion (10 or more red cell transfusions). Secondary outcomes included 28-day mortality. Pre-specified subgroups included patients with severe traumatic brain injury (TBI). RESULTS Of 396 patients in the intention to treat analysis, 201 were allocated to VHA and 195 to CCT-guided therapy. At 24 h, there was no difference in the proportion of patients who were alive and free of massive transfusion (VHA: 67%, CCT: 64%, OR 1.15, 95% CI 0.76-1.73). 28-day mortality was not different overall (VHA: 25%, CCT: 28%, OR 0.84, 95% CI 0.54-1.31), nor were there differences in other secondary outcomes or serious adverse events. In pre-specified subgroups, there were no differences in primary outcomes. In the pre-specified subgroup of 74 patients with TBI, 64% were alive and free of massive transfusion at 24 h compared to 46% in the CCT arm (OR 2.12, 95% CI 0.84-5.34). CONCLUSION There was no difference in overall outcomes between VHA- and CCT-augmented-major haemorrhage protocols.
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Affiliation(s)
| | - L S Gall
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - J Stensballe
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - N P Juffermans
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - N Curry
- Oxford University Hospital NHS Trust, Oxford, UK
| | - M Maegele
- Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - A Brooks
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - C Rourke
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - S Gillespie
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - J Murphy
- Queen Mary University of London, London, UK
| | - R Maroni
- Queen Mary University of London, London, UK
| | - P Vulliamy
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - H H Henriksen
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - K Holst Pedersen
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - M R Wirtz
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - D J B Kleinveld
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - N Schäfer
- Cologne-Merheim Medical Centre, University of Witten/Herdecke, Cologne, Germany
| | - S Chinna
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R A Davenport
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - P A Naess
- Oslo University Hospital & University of Oslo, Oslo, Norway
| | - J C Goslings
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - S Eaglestone
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK
| | - S Stanworth
- Oxford University Hospital NHS Trust, Oxford, UK.,NHS Blood and Transplant, Bristol, UK
| | - P I Johansson
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - C Gaarder
- Oslo University Hospital & University of Oslo, Oslo, Norway
| | - K Brohi
- Centre for Trauma Sciences, Queen Mary University of London, Blizard Institute, 4 Newark Street, London, E1 2AT, UK.
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28
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Upadhyaya GK, Iyengar KP, Jain VK, Garg R. Evolving concepts and strategies in the management of polytrauma patients. J Clin Orthop Trauma 2021; 12:58-65. [PMID: 33716429 PMCID: PMC7920163 DOI: 10.1016/j.jcot.2020.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/04/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023] Open
Abstract
Major trauma is one of the leading causes of morbidity and mortality in young adults. The impact of disability on the quality of life and functionality in this younger population is worrisome. This remains a major public health concern across the globe. Immediate and early deaths account for nearly 80% of trauma deaths occurring within the first few hours of injury to the first few days, usually because of traumatic brain injury or major exsanguination and subsequently due to shock or hypoxia. Worldwide adoption of comprehensive trauma systems and evolving models of trauma care including prehospital interventions have led improvements in trauma and critical care over the last few decades. Resuscitation and damage control orthopaedics are two key pillars in the management of polytrauma patient. Trauma-related coagulopathy can be an emerging complication during resuscitation of such patients which should be recognized early so appropriate corrective measures can be undertaken. We describe the evolving models of care in the management of polytrauma and trauma associated coagulopathy.
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Affiliation(s)
- Gaurav K. Upadhyaya
- Department of Orthopaedics, All India Institute of Medical Sciences, Raebareli, UP, 229405, India
| | | | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
- Corresponding author. Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India.
| | - Rakesh Garg
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
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Salamea-Molina JC, Himmler AN, Valencia-Angel LI, Ordoñez CA, Parra MW, Caicedo Y, Guzmán-Rodríguez M, Orlas C, Granados M, Macia C, García A, Serna JJ, Badiel M, Puyana JC. Whole blood for blood loss: hemostatic resuscitation in damage control. Colomb Med (Cali) 2020; 51:e4044511. [PMID: 33795899 PMCID: PMC7968429 DOI: 10.25100/cm.v51i4.4511] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/25/2020] [Accepted: 12/18/2020] [Indexed: 12/23/2022] Open
Abstract
Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.
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Affiliation(s)
- Juan Carlos Salamea-Molina
- Hospital Vicente Corral Moscoso, Division of Trauma and Acute Care Surgery, Cuenca, Ecuador
- Universidad del Azuay, Escuela de Medicina. Cuenca, Ecuador
| | - Amber Nicole Himmler
- Medstar Georgetown University Hospital, Department of Surgery, Washington, D.C., USA
- Washington Hospital Center. Washington, D.C., USA
| | - Laura Isabel Valencia-Angel
- Universidad Industrial de Santander, Department of Surgery, Bucaramanga, Colombia
- Hospital Manuela Beltrán, Department of Surgery, Socorro, Colombia
| | - Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Claudia Orlas
- Brigham & Women's Hospital, Department of Surgery, Center for Surgery and Public Health, Boston, USA
- Harvard Medical School & Harvard T.H., Chan School of Public Health, Boston - USA
| | | | - Carmenza Macia
- Fundación Valle del Lili, Blood Bank and Transfusion Service, Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
- Universidad Icesi, Cali, Colombia
- Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
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Vishwanathan K, Chhajwani S, Gupta A, Vaishya R. Evaluation and management of haemorrhagic shock in polytrauma: Clinical practice guidelines. J Clin Orthop Trauma 2020; 13:106-115. [PMID: 33680808 PMCID: PMC7919934 DOI: 10.1016/j.jcot.2020.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022] Open
Abstract
Haemorrhagic shock is the most common preventable cause of early mortality in polytrauma patients. Road traffic injuries are the most common cause for polytrauma and most commonly include orthopaedic injuries. Hence, orthopaedic trainees and junior orthopaedic surgeons need to be well aware of evaluation and management of haemorrhagic shock in the multiple injured patient. The present narrative review discusses evaluation and current principles in management of haemorrhagic shock in a polytrauma patient. A classification system for haemorrhagic shock based on ATLS guidelines has been described along with novel use of colour coding to facilitate better and effective use of the classification. A treatment algorithm has also been presented for quick reference. The emphasis is to avoid overloading with crystalloid fluids, replacing with blood and blood products (Balanced resuscitation), permissive hypotension, prevent and acutely treat lethal conditions such as hypothermia, acidosis and coagulopathy. The management of haemorrhagic shock in polytrauma patient is quite challenging and require a detailed knowledge of its management. An arbitrary and haphazard management of these patients may lead to severe complications. We have mentioned the broad principles of management of hypovolemic shock in a polytrauma patient.
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Affiliation(s)
- Karthik Vishwanathan
- Department of Orthopaedics, Parul Institute of Medical Sciences and Research, Parul University, Vadodara, India
- Corresponding author. Department of Orthopaedics, Parul Institute of Medical Sciences and Research, Faculty of Medicine, Parul University, P.O Limda, Waghodia, Vadodara, 391760, India.
| | - Sunil Chhajwani
- Department of Anaesthesia and Critical Care, Pramukhswami Medical College, Karamsad, India
| | - Amit Gupta
- Division of Trauma Surgery & Critical Care, J.P.N. Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Vaishya
- Department of Orthopaedics & Joint Replacement, Indraprastha Apollo Hospitals, New Delhi, India
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Selby R. "TEG talk": expanding clinical roles for thromboelastography and rotational thromboelastometry. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:67-75. [PMID: 33275705 PMCID: PMC7727516 DOI: 10.1182/hematology.2020000090] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Viscoelastic assays (VEAs) that include thromboelastography and rotational thromboelastometry add value to the investigation of coagulopathies and goal-directed management of bleeding by providing a complete picture of clot formation, strength, and lysis in whole blood that includes the contribution of platelets, fibrinogen, and coagulation factors. Conventional coagulation assays have several limitations, such as their lack of correlation with bleeding and hypercoagulability; their inability to reflect the contribution of platelets, factor XIII, and plasmin during clot formation and lysis; and their slow turnaround times. VEA-guided transfusion algorithms may reduce allogeneic blood exposure during and after cardiac surgery and in the emergency management of trauma-induced coagulopathy and hemorrhage. However, the popularity of VEAs for other indications is driven largely by extrapolation of evidence from cardiac surgery, by the drawbacks of conventional coagulation assays, and by institution-specific preferences. Robust diagnostic studies validating and standardizing diagnostic cutoffs for VEA parameters and randomized trials comparing VEA-guided algorithms with standard care on clinical outcomes are urgently needed. Lack of such studies represents the biggest barrier to defining the role and impact of VEA in clinical care.
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Affiliation(s)
- Rita Selby
- Department of Laboratory Medicine and Pathobiology and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Roche TR, Said S, Rössler J, Gozdzik M, Meybohm P, Zacharowski K, Spahn DR, Nöthiger CB, Tscholl DW. Physicians' Perceptions of a Situation Awareness-Oriented Visualization Technology for Viscoelastic Blood Coagulation Management (Visual Clot): Mixed Methods Study. JMIR Serious Games 2020; 8:e19036. [PMID: 33172834 PMCID: PMC7748952 DOI: 10.2196/19036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/16/2020] [Accepted: 11/10/2020] [Indexed: 01/17/2023] Open
Abstract
Background Viscoelastic tests enable a time-efficient analysis of coagulation properties. An important limitation of viscoelastic tests is the complicated presentation of their results in the form of abstract graphs with a multitude of numbers. We developed Visual Clot to simplify the interpretation of presented clotting information. This visualization technology applies user-centered design principles to create an animated model of a blood clot during the hemostatic cascade. In a previous simulation study, we found Visual Clot to double diagnostic accuracy, reduce time to decision making and perceived workload, and improve care providers’ confidence. Objective This study aimed to investigate the opinions of physicians on Visual Clot technology. It further aimed to assess its strengths, limitations, and clinical applicability as a support tool for coagulation management. Methods This was a researcher-initiated, international, double-center, mixed qualitative-quantitative study that included the anesthesiologists and intensive care physicians who participated in the previous Visual Clot study. After the participants solved six coagulation scenarios using Visual Clot, we questioned them about the perceived pros and cons of this new tool. Employing qualitative research methods, we identified recurring answer patterns, and derived major topics and subthemes through inductive coding. Based on them, we defined six statements. The study participants later rated their agreement to these statements on five-point Likert scales in an online survey, which represented the quantitative part of this study. Results A total of 60 physicians participated in the primary Visual Clot study. Among these, 36 gave an interview and 42 completed the online survey. In total, eight different major topics were derived from the interview field note responses. The three most common topics were “positive design features” (29/36, 81%), “facilitates decision making” (17/36, 47%), and “quantification not made” (17/36, 47%). In the online survey, 93% (39/42) agreed to the statement that Visual Clot is intuitive and easy to learn. Moreover, 90% (38/42) of the participants agreed that they would like the standard result and Visual Clot displayed on the screen side by side. Furthermore, 86% (36/42) indicated that Visual Clot allows them to deal with complex coagulation situations more quickly. Conclusions A group of anesthesia and intensive care physicians from two university hospitals in central Europe considered Visual Clot technology to be intuitive, easy to learn, and useful for decision making in situations of active bleeding. From the responses of these possible future users, Visual Clot appears to constitute an efficient and well-accepted way to streamline the decision-making process in viscoelastic test–based coagulation management.
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Affiliation(s)
- Tadzio Raoul Roche
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Sadiq Said
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Julian Rössler
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Malgorzata Gozdzik
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Patrick Meybohm
- Department of Anesthesiology, University Hospital Würzburg, Würzburg, Germany
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Donat R Spahn
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Christoph B Nöthiger
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - David W Tscholl
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zürich, Switzerland
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Walker CB, Moore HB, Nydam TL, Schulick AC, Yaffe H, Pomposelli JJ, Wachs M, Bak T, Conzen K, Adams M, Pshak T, Choudhury R, Chapman MP, Pomfret EA, Kennealey P. The use of thromboelastography to assess post-operative changes in coagulation and predict graft function in renal transplantation. Am J Surg 2020; 220:1511-1517. [PMID: 32878689 PMCID: PMC7450953 DOI: 10.1016/j.amjsurg.2020.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/28/2020] [Accepted: 08/19/2020] [Indexed: 11/01/2022]
Abstract
BACKGROUND End stage renal disease (ESRD) is associated with elevated fibrinogen levels and fibrinolysis inhibition. However, there is a paucity of data on how renal transplantation impacts coagulation. we hypothesize that renal transplantation recipients with good functioning grafts will have improved fibrinolytic activity following surgery. METHODS Kidney recipients were analyzed pre-operatively and on post-operative day 1(POD1) using three different TEG assays with and without two concentration of tissue-plasminogen activator (t-PA). TEG indices and percent reduction in creatinine from pre-op to POD1 were measured, with >50% defining "good" graft function. Follow up was done at 6, 12, and 24 months. RESULTS Percent lysis(LY30) on POD1 the t-PA TEG was significantly correlated to change creatinine from pre-op to POD-1(p = 0.006). A LY30 ≥ 23% was associated with good early graft function, and lower creatinine at 24-months(p = 0.028) compared to recipients with low POD1 LY30. CONCLUSIONS Post-operative tPA-TEG LY30 is associated with favorable early and late outcomes in kidney transplant.
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Affiliation(s)
- Carson B Walker
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Hunter B Moore
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA.
| | - Trevor L Nydam
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Alexander C Schulick
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Hillary Yaffe
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - James J Pomposelli
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Michael Wachs
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Thomas Bak
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Kendra Conzen
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Megan Adams
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Thomas Pshak
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Rashikh Choudhury
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Michael P Chapman
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Elizabeth A Pomfret
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
| | - Peter Kennealey
- Department of Surgery, Division of Transplant Surgery, University of Colorado, USA
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Pavoni V, Gianesello L, Pazzi M, Stera C, Meconi T, Frigieri FC. Evaluation of coagulation function by rotation thromboelastometry in critically ill patients with severe COVID-19 pneumonia. J Thromb Thrombolysis 2020; 50:281-286. [PMID: 32394236 PMCID: PMC7211560 DOI: 10.1007/s11239-020-02130-7] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Critically ill patients with COVID-19 pneumonia suffered both high thrombotic and bleeding risk. The effect of SARS-CoV-2 on coagulation and fibrinolysis is not well known. We conducted a retrospective study of critically ill patients admitted to an intensive care unit (ICU) a cause of severe COVID-19 pneumonia and we evaluated coagulation function using rotational thromboelastometry (ROTEM) on day of admission (T0) and 5 (T5) and 10 (T10) days after admission to ICU. Coagulation standard parameters were also evaluated. Forty patients were enrolled into the study. The ICU and the hospital mortality were 10% and 12.5%, respectively. On ICU admission, prothrombin time was slightly reduced and it increased significantly at T10 (T0 = 65.1 ± 9.8 vs T10 = 85.7 ± 1.5, p = 0.002), while activated partial thromboplastin time and fibrinogen values were higher at T0 than T10 (32.2 ± 2.9 vs 27.2 ± 2.1, p = 0.017 and 895.1 ± 110 vs 332.5 ± 50, p = 0.002, respectively); moreover, whole blood thromboelastometry profiles were consistent with hypercoagulability characterized by an acceleration of the propagation phase of blood clot formation [i.e., CFT below the lower limit in INTEM 16/40 patients (40%) and EXTEM 20/40 patients (50%)] and significant higher clot strength [MCF above the upper limit in INTEM 20/40 patients (50%), in EXTEM 28/40 patients (70%) and in FIBTEM 29/40 patients (72.5%)]; however, this hypercoagulable state persists in the first five days, but it decreases ten day after, without returning to normal values. No sign of secondary hyperfibrinolysis or sepsis induced coagulopathy (SIC) were found during the study period. In six patients (15%) a deep vein thrombosis and in 2 patients (5%) a thromboembolic event, were found; 12 patients (30%) had a catheter-related thrombosis. ROTEM analysis confirms that patients with severe COVID-19 pneumonia had a hypercoagulation state that persisted over time.
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Affiliation(s)
- Vittorio Pavoni
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, Florence, Italy.
| | - Maddalena Pazzi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Caterina Stera
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Tommaso Meconi
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
| | - Francesca Covani Frigieri
- Emergency Department and Critical Care Area, Anesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, Florence, Italy
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Brearton C, Rushton A, Parker J, Martin H, Hodgson J. Performance Evaluation of a New Point of Care Viscoelastic Coagulation Monitoring System in Major Abdominal, Orthopaedic and Vascular Surgery. Platelets 2020; 31:1052-1059. [DOI: 10.1080/09537104.2019.1704719] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Chris Brearton
- Department of Anaesthesia, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Andrew Rushton
- Department of Anaesthesia, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Jane Parker
- Department of Anaesthesia, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Hannah Martin
- Thornton Science Park, Medtechtomarket Consulting Ltd, Chester, UK
| | - Jake Hodgson
- Thornton Science Park, Medtechtomarket Consulting Ltd, Chester, UK
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Nair AB, Parker RI. Hemostatic Testing in Critically Ill Infants and Children. Front Pediatr 2020; 8:606643. [PMID: 33490001 PMCID: PMC7820389 DOI: 10.3389/fped.2020.606643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/10/2020] [Indexed: 12/12/2022] Open
Abstract
Children with critical illness frequently manifest imbalances in hemostasis with risk of consequent bleeding or pathologic thrombosis. Traditionally, plasma-based tests measuring clot formation by time to fibrin clot generation have been the "gold standard" in hemostasis testing. However, these tests are not sensitive to abnormalities in fibrinolysis or in conditions of enhanced clot formation that may lead to thrombosis. Additionally, they do not measure the critical roles played by platelets and endothelial cells. An added factor in the evaluation of these plasma-based tests is that in infants and young children plasma levels of many procoagulant and anticoagulant proteins are lower than in older children and adults resulting in prolonged clot generation times in spite of maintaining a normal hemostatic "balance." Consequently, newer assays directly measuring thrombin generation in plasma and others assessing the stages hemostasis including clot initiation, propagation, and fibrinolysis in whole blood by viscoelastic methods are now available and may allow for a global measurement of the hemostatic system. In this manuscript, we will review the processes by which clots are formed and by which hemostasis is regulated, and the rationale and limitations for the more commonly utilized tests. We will also discuss selected newer tests available for the assessment of hemostasis, their "pros" and "cons," and how they compare to the traditional tests of coagulation in the assessment and management of critically ill children.
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Affiliation(s)
- Alison B Nair
- Pediatric Critical Care Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Robert I Parker
- Pediatric Hematology/Oncology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
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Kichloo A, Dettloff K, Aljadah M, Albosta M, Jamal S, Singh J, Wani F, Kumar A, Vallabhaneni S, Khan MZ. COVID-19 and Hypercoagulability: A Review. Clin Appl Thromb Hemost 2020; 26:1076029620962853. [PMID: 33074732 PMCID: PMC7592310 DOI: 10.1177/1076029620962853] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 01/08/2023] Open
Abstract
Thrombotic complications of the novel coronavirus (COVID-19) are a concerning aspect of the disease, due to the high incidence in critically ill patients and poor clinical outcomes. COVID-19 predisposes patients to a hypercoagulable state, however, the pathophysiology behind the thrombotic complications seen in this disease is not well understood. Several mechanisms have been proposed and the pathogenesis likely involves a host immune response contributing to vascular endothelial cell injury, inflammation, activation of the coagulation cascade via tissue factor expression, and shutdown of fibrinolysis. Treatments targeting these pathways may need to be considered to improve clinical outcomes and decrease overall mortality due to thrombotic complications. In this review, we will discuss the proposed pathophysiologic mechanisms for thrombotic complications in COVID-19, as well as treatment strategies for these complications based on the current literature available.
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Affiliation(s)
- Asim Kichloo
- St. Mary’s of Saginaw Hospital, Saginaw, MI, USA
- Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Kirk Dettloff
- Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Michael Aljadah
- Medical College of Wisconsin Affiliated Hospitals, Milwaukee, WI, USA
| | - Michael Albosta
- Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Shakeel Jamal
- St. Mary’s of Saginaw Hospital, Saginaw, MI, USA
- Central Michigan University College of Medicine, Saginaw, MI, USA
| | - Jagmeet Singh
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Farah Wani
- Samaritan Medical Center, Watertown, NY, USA
| | - Akshay Kumar
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Tritapepe L, Carriero G. Are there real or semantic differences between thromboelastography and thromboelastometry? Minerva Anestesiol 2019; 85:1262-1264. [DOI: 10.23736/s0375-9393.19.14248-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Vernon T, Morgan M, Morrison C. Bad blood: A coagulopathy associated with trauma and massive transfusion review. Acute Med Surg 2019; 6:215-222. [PMID: 31304022 PMCID: PMC6603326 DOI: 10.1002/ams2.402] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 02/02/2019] [Indexed: 12/14/2022] Open
Abstract
Coagulopathy in trauma patients is a known contributor to death due to hemorrhage. In fact, it seen as frequently as 35% of the time. The complexity of the coagulopathy pathway requires a deliberate and planned approach. The methods used to assess and detect if a patient is coagulopathic remain challenging, but tools have been developed to assist the practitioner to effectively manage and even quickly reverse the coagulopathy. The purpose of this review is to educate trauma and emergency medicine staff on the currently available diagnostic tools to assess coagulopathy, to provide an overview of the coagulopathy pathway, as well as provide examples of how to intervene and treat coagulopathy, including the use of crew resource management during mass transfusion protocol activations.
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Affiliation(s)
- Tawnya Vernon
- Trauma ServicesPenn Medicine Lancaster General HealthLancasterPennsylvania
| | - Madison Morgan
- Trauma ServicesPenn Medicine Lancaster General HealthLancasterPennsylvania
| | - Chet Morrison
- Trauma ServicesPenn Medicine Lancaster General HealthLancasterPennsylvania
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Walsh M, Moore EE, Moore H, Thomas S, Lune SV, Zimmer D, Dynako J, Hake D, Crowell Z, McCauley R, Larson EE, Miller M, Pohlman T, Achneck HE, Martin P, Nielsen N, Shariff F, Ploplis VA, Castellino FJ. Use of Viscoelastography in Malignancy-Associated Coagulopathy and Thrombosis: A Review. Semin Thromb Hemost 2019; 45:354-372. [PMID: 31108555 PMCID: PMC7707018 DOI: 10.1055/s-0039-1688497] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The relationship between malignancy and coagulopathy is one that is well documented yet incompletely understood. Clinicians have attempted to quantify the hypercoagulable state produced in various malignancies using common coagulation tests such as prothrombin time, activated partial thromboplastin time, and platelet count; however, due to these tests' focus on individual aspects of coagulation during one specific time point, they have failed to provide clinicians the complete picture of malignancy-associated coagulopathy (MAC). Viscoelastic tests (VETs), such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM), are whole blood analyses that have the advantage of providing information related to the cumulative effects of plasma clotting factors, platelets, leukocytes, and red cells during all stages of the coagulation and fibrinolytic processes. VETs have gained popularity in the care of trauma patients to objectively measure trauma-induced coagulopathy (TIC), but the utility of VETs remains yet unrealized in many other medical specialties. The authors discuss the similarities and differences between TIC and MAC, and propose a mechanism for the hypercoagulable state of MAC that revolves around the thrombomodulin-thrombin complex as it switches between activating the protein C anticoagulation pathway or the thrombin activatable fibrinolysis inhibitor coagulation pathway. Additionally, they review the current literature on the use of TEG and ROTEM in patients with various malignancies. Although limited research is currently available, early results demonstrate the utility of both TEG and ROTEM in the prediction of hypercoagulable states and thromboembolic complications in oncologic patients.
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Affiliation(s)
- Mark Walsh
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Ernest E. Moore
- Ernest E. Moore Trauma Center Denver General Hospital, University of Colorado School of Medicine, Denver, Colorado
| | - Hunter Moore
- Ernest E. Moore Trauma Center Denver General Hospital, University of Colorado School of Medicine, Denver, Colorado
| | - Scott Thomas
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | - Stefani Vande Lune
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - David Zimmer
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Joseph Dynako
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Daniel Hake
- Chicago College of Osteopathic Medicine at Midwestern University, Downers Grove, Illinois
| | - Zachary Crowell
- Chicago College of Osteopathic Medicine at Midwestern University, Downers Grove, Illinois
| | - Ross McCauley
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Emilee E. Larson
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Michael Miller
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | - Tim Pohlman
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | | | - Peter Martin
- Department of Emergency Medicine, Tulane School of Medicine, New Orleans, Louisiana
| | - Nathan Nielsen
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane School of Medicine, New Orleans, Louisiana
| | - Faisal Shariff
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Victoria A. Ploplis
- W.M. Keck Center for Transgene Research, The University of Notre Dame, Notre Dame, Indiana
- Department of Chemistry and Biochemistry, The University of Notre Dame, Notre Dame, Indiana
| | - Francis J. Castellino
- W.M. Keck Center for Transgene Research, The University of Notre Dame, Notre Dame, Indiana
- Department of Chemistry and Biochemistry, The University of Notre Dame, Notre Dame, Indiana
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Thorn S, Lefering R, Maegele M, Gruen RL, Mitra B. Early prediction of acute traumatic coagulopathy: a validation of the COAST score using the German Trauma Registry. Eur J Trauma Emerg Surg 2019; 47:333-341. [PMID: 31037353 DOI: 10.1007/s00068-019-01142-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 04/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Early identification of trauma patients at risk of developing acute traumatic coagulopathy (ATC) is important for initiating appropriate, coagulopathy-focused treatment. A clinical ATC prediction tool is a quick, simple method to evaluate risk. The COAST score was developed and validated in Australia but is yet to be validated on a European population. We validated the ability of the COAST score to predict coagulopathy and adverse bleeding-related outcomes on a large European trauma population. METHODS The COAST score was modified and applied to a retrospective cohort of trauma patients from the German Trauma Registry (TR-DGU). The primary outcome was coagulopathy defined as INR > 1.5 or aPTT > 60 s. Secondary outcomes were massive transfusion, blood product requirements, urgent surgery and mortality. The cohort included adult trauma patients with Injury Severity Score > 15 treated in Germany/Austria in 2012-2016. RESULTS 15,370 cases were included, of which 10.9% were coagulopathic. The COAST score performed with sensitivity 21.6% and specificity 94.2% at a threshold of COAST ≥ 3. The AUROC was 0.625 (95% CI 0.61-0.64). The COAST score also identified patients who had more massive transfusions (15.3% v 1.6%), more emergency surgery (49.6% v 28.2%), and higher early (21.7% v 5.4%) and total in-hospital mortality (38.1% v 14.5%). CONCLUSION This large retrospective study demonstrated that the modified COAST score predicts coagulopathy with low sensitivity but high specificity. A positive COAST score identified a group of patients with bleeding-related adverse outcomes. This score appears adequate to act as an inclusion criterion for clinical trials targeting ATC.
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Affiliation(s)
- Sophie Thorn
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia. .,Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany.
| | - Rolf Lefering
- Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
| | - Marc Maegele
- Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany.,Department of Traumatology and Orthopaedic Surgery, Cologne-Merheim Medical Centre, Cologne, Germany
| | - Russell L Gruen
- College of Health and Medicine, The Australian National University, Canberra, Australia
| | - Biswadev Mitra
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,National Trauma Research Institute, Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia
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Ishii K, Kinoshita T, Kiridume K, Watanabe A, Yamakawa K, Nakao S, Fujimi S, Matsuoka T. Impact of initial coagulation and fibrinolytic markers on mortality in patients with severe blunt trauma: a multicentre retrospective observational study. Scand J Trauma Resusc Emerg Med 2019; 27:25. [PMID: 30819212 PMCID: PMC6394102 DOI: 10.1186/s13049-019-0606-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 02/19/2019] [Indexed: 02/06/2023] Open
Abstract
Background Acute coagulopathy is a well-known predictor of poor outcomes in patients with severe trauma. However, using coagulation and fibrinolytic markers, how one can best predict mortality to find out potential candidates for treatment of coagulopathy remains unclear. This study aimed to determine preferential markers and their optimal cut-off values for mortality prediction. Methods We conducted a retrospective observational study of patients with severe blunt trauma (injury severity score ≥ 16) transferred directly from the scene to emergency departments at two trauma centres in Japan from January 2013 to December 2015. We investigated the impact and optimal cut-off values of initial coagulation (platelet counts, fibrinogen and prothrombin time-international normalised ratio) and a fibrinolytic marker (D-dimer) on 28-day mortality via classification and regression tree (CART) analysis. Multivariate logistic regression analysis confirmed the importance of these markers. Receiver operating characteristic curve analyses were used to examine the prediction accuracy for mortality. Results Totally 666 patients with severe blunt trauma were analysed. CART analysis revealed that the initial discriminator was fibrinogen (cut-off, 130 mg/dL) and the second discriminator was D-dimer (cut-off, 110 μg/mL in the lower fibrinogen subgroup; 118 μg/mL in the higher fibrinogen subgroup). The 28-day mortality was 90.0% (lower fibrinogen, higher D-dimer), 27.8% (lower fibrinogen, lower D-dimer), 27.7% (higher fibrinogen, higher D-dimer) and 3.4% (higher fibrinogen, lower D-dimer). Multivariate logistic regression demonstrated that fibrinogen levels < 130 mg/dL (adjusted odds ratio [aOR], 9.55; 95% confidence interval [CI], 4.50–22.60) and D-dimer ≥110 μg/mL (aOR, 5.89; 95% CI, 2.78–12.70) were independently associated with 28-day mortality after adjusting for probability of survival by the trauma and injury severity score (TRISS Ps). Compared with the TRISS Ps alone (0.900; 95% CI, 0.870–0.931), TRISS Ps with fibrinogen and D-dimer yielded a significantly higher area under the curve (0.942; 95% CI, 0.920–0.964; p < 0.001). Conclusions Fibrinogen and D-dimer were the principal markers for stratification of mortality in patients with severe blunt trauma. These markers could function as therapeutic targets because they were significant predictors of mortality, independent from severity of injury.
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Affiliation(s)
- Kenta Ishii
- Department of Trauma and Critical Care, Rinku General Medical Centre, Senshu Trauma and Critical Care Centre, 2-23 Rinku Orai-kita, Izumisano, Osaka, 598-8577, Japan.
| | - Takahiro Kinoshita
- Division of Trauma and Surgical Critical Care, Osaka General Medical Centre, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Kazutaka Kiridume
- Department of Trauma and Critical Care, Rinku General Medical Centre, Senshu Trauma and Critical Care Centre, 2-23 Rinku Orai-kita, Izumisano, Osaka, 598-8577, Japan
| | - Atsushi Watanabe
- Division of Trauma and Surgical Critical Care, Osaka General Medical Centre, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Centre, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Shota Nakao
- Department of Trauma and Critical Care, Rinku General Medical Centre, Senshu Trauma and Critical Care Centre, 2-23 Rinku Orai-kita, Izumisano, Osaka, 598-8577, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Centre, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Tetsuya Matsuoka
- Department of Trauma and Critical Care, Rinku General Medical Centre, Senshu Trauma and Critical Care Centre, 2-23 Rinku Orai-kita, Izumisano, Osaka, 598-8577, Japan
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Govil D, Pal D. Point-of-care Testing of Coagulation in Intensive Care Unit: Role of Thromboelastography. Indian J Crit Care Med 2019; 23:S202-S206. [PMID: 31656379 PMCID: PMC6785812 DOI: 10.5005/jp-journals-10071-23253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Govil D, Pal D. Point-of-care Testing of Coagulation in Intensive Care Unit: Role of Thromboelastography. Indian J Crit Care Med 2019;23(Suppl 3):S202–S206.
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Affiliation(s)
- Deepak Govil
- Department of Critical Care Medicine, Medanta: The Medicity, Gurugram, Haryana, India
| | - Divya Pal
- Department of Critical Care Medicine, Medanta: The Medicity, Gurugram, Haryana, India
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Koo BN, Kwon MA, Kim SH, Kim JY, Moon YJ, Park SY, Lee EH, Chae MS, Choi SU, Choi JH, Hwang JY. Korean clinical practice guideline for perioperative red blood cell transfusion from Korean Society of Anesthesiologists. Korean J Anesthesiol 2018; 72:91-118. [PMID: 30513567 PMCID: PMC6458508 DOI: 10.4097/kja.d.18.00322] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/27/2018] [Indexed: 01/28/2023] Open
Abstract
Background Considering the functional role of red blood cells (RBC) in maintaining oxygen supply to tissues, RBC transfusion can be a life-saving intervention in situations of severe bleeding or anemia. RBC transfusion is often inevitable to address intraoperative massive bleeding; it is a key component in safe perioperative patient management. Unlike general medical resources, packed RBCs (pRBCs) have limited availability because their supply relies entirely on voluntary donations. Additionally, excessive utilization of pRBCs may aggravate prognosis or increase the risk of developing infectious diseases. Appropriate perioperative RBC transfusion is, therefore, crucial for the management of patient safety and medical resource conservation. These concerns motivated us to develop the present clinical practice guideline for evidence-based efficient and safe perioperative RBC transfusion management considering the current clinical landscape. Methods This guideline was obtained after the revision and refinement of exemplary clinical practice guidelines developed in advanced countries. This was followed by rigorous evidence-based reassessment considering the healthcare environment of the country. Results This guideline covers all important aspects of perioperative RBC transfusion, such as preoperative anemia management, appropriate RBC storage period, and leukoreduction (removal of white blood cells using filters), reversal of perioperative bleeding tendency, strategies for perioperative RBC transfusion, appropriate blood management protocols, efforts to reduce blood transfusion requirements, and patient monitoring during a perioperative transfusion. Conclusions This guideline will aid decisions related to RBC transfusion in healthcare settings and minimize patient risk associated with unnecessary pRBC transfusion.
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Affiliation(s)
- Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min A Kwon
- Department of Anesthesiology and Pain Medicine, Dankook University Hospital, Cheonan, Korea
| | - Sang-Hyun Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jong Yeop Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun Young Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Uk Choi
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jeong-Hyun Choi
- Department of Anesthesiology and Pain Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jin-Young Hwang
- Department of Anesthesiology and Pain Medicine, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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Nam K, Jeon Y, Kim TK, Jo WY, Yoon S, Kwak J, Cho YJ. The velocity curve of the clotting waveform of rotational thromboelastometry predicts bleeding after cardiac surgery but conventional rotational thromboelastometric parameters do not. Minerva Anestesiol 2018; 85:505-513. [PMID: 30394063 DOI: 10.23736/s0375-9393.18.12960-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early detection of a risk of postoperative bleeding is essential in cardiac surgery patients. The aim of the present study was to evaluate the utility of the first derivative curve (the V-curve) of the clotting waveform of rotational thromboelastometry (ROTEM) in terms of predicting bleeding after cardiac surgery. METHODS We retrospectively analysed 534 cardiac surgery patients. We used the chest tube output during the stay in the intensive care unit to divide patients into a higher blood loss group (HBL group; the fourth quartile) and a lower blood loss group (LBL group; the lower quartiles). We performed multivariable logistic regression using the V-curve parameters and potential confounders including conventional ROTEM parameters. RESULTS In the multivariable model, the adjusted odds ratios for HBL of patients with a lower maximum clotting velocity (MaxVel ≤9 mm*100 s-1) as revealed by extrinsically activated ROTEM (EXTEM), and the area under the velocity curve (AUC ≤988 mm*100) of the fibrin-based extrinsically activated ROTEM (FIBTEM), both measured at skin closure in the end of surgery, were 1.78 (95% CI 1.03 to 3.07) and 2.14 (95% CI 1.20 to 3.82), respectively. However, conventional ROTEM parameters were not included in the final model. Additionally, lower EXTEM MaxVel and FIBTEM AUC values were associated with the need for a higher transfusion volume, longer postoperative intensive care unit and hospital stays, and more frequent re-exploration to control bleeding. CONCLUSIONS The ROTEM V-curve parameters can predict postoperative bleeding and clinical outcomes after cardiac surgery.
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Affiliation(s)
- Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Tae K Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Woo Y Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sehee Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jooah Kwak
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Youn J Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea -
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Abraha I, Montedori A, Di Renzo GC, Angelozzi P, Micheli M, Carloni D, Germani A, Palmieri G, Casali M, Nenz CMG, Gargano E, Pazzaglia M, Berchicci L, Tesoro S, Epicoco G, Giovannini G, Marchesi M. Diagnostic, preventive and therapeutic evidence in obstetrics for the implementation of patient blood management: a systematic review protocol. BMJ Open 2018; 8:e021322. [PMID: 30327399 PMCID: PMC6196839 DOI: 10.1136/bmjopen-2017-021322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Patientblood management (PBM) is defined as the application of evidence-based diagnostic, preventive and therapeutic approaches designed to maintain haemoglobin concentration, optimise haemostasis and minimise blood loss in an effort to improve patient outcome. We propose a protocol for the assessment of the evidence of diagnostic, preventive and therapeutic approaches for the management of relevant outcomes in obstetrics with the aim to create a framework for PBM implementation. METHODS AND ANALYSIS Diagnostic, preventive and therapeutic tools will be considered in the gynaecological conditions and obstetrics setting (antenatal care, peripartum care and maternity care). For each condition, (1) clinical questions based on prioritised outcomes will be developed; (2) evidence will be retrieved systematically from electronic medical literature (MEDLINE, EMBASE, the Cochrane Library, Web of Science, and CINAHL); (3) quality of the reviews will be assessed using the AMSTAR (A Measurement Tool to Assess Systematic Reviews) checklist; quality of primary intervention studies will be assessed using the risk of bias tool (Cochrane method); quality of diagnostic primary studies will be assessed using QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies); (4) the Grading of Recommendations Assessment, Development and Evaluation method will be applied to rate the quality of the evidence and to develop recommendations. ETHICS AND DISSEMINATION For each diagnostic, preventive or therapeutic intervention evaluated, a manuscript comprising the evidence retrieved and the recommendation produced will be provided and published in peer-reviewed journals. Ethical approval is not required.
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Affiliation(s)
- Iosief Abraha
- Centro Regionale Sangue, Servizio Immunotrasfusionale, Azienda Ospedaliera di Perugia, Perugia, Italy
- Health Planning Service, Regional Health Authority of Umbria, Perugia, Italy
| | | | - Gian Carlo Di Renzo
- Clinica Ostetrica e Ginecologica, Policlinico, Università di Perugia, Perugia, Italy
| | | | - Marta Micheli
- Servizio Immunotrasfusionale, USL Umbria 2, Foligno, Italy
| | | | | | - Gianluca Palmieri
- Servizio Immunotrasfusionale, Azienda Ospedaliera Santa Maria di Terni, Terni, Italy
| | - Marta Casali
- Anestesia e Rianimazione, Azienda Ospedaliera Santa Maria di Terni, Terni, Italy
| | | | | | | | | | - Simonetta Tesoro
- Anestesia e Rianimazione, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Giorgio Epicoco
- Ginecologia e Ostetricia, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Gianni Giovannini
- Health Planning Service, Regional Health Authority of Umbria, Perugia, Italy
| | - Mauro Marchesi
- Centro Regionale Sangue, Servizio Immunotrasfusionale, Azienda Ospedaliera di Perugia, Perugia, Italy
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Kobayashi LM, Brito A, Barmparas G, Bosarge P, Brown CV, Bukur M, Carrick MM, Catalano RD, Holly-Nicolas J, Inaba K, Kaminski S, Klein AL, Kopelman T, Ley EJ, Martinez EM, Moore FO, Murry J, Nirula R, Paul D, Quick J, Rivera O, Schreiber M, Coimbra R. Laboratory measures of coagulation among trauma patients on NOAs: results of the AAST-MIT. Trauma Surg Acute Care Open 2018; 3:e000231. [PMID: 30402564 PMCID: PMC6203140 DOI: 10.1136/tsaco-2018-000231] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 09/11/2018] [Accepted: 09/15/2018] [Indexed: 12/22/2022] Open
Abstract
Background Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG). Methods This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman's rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups. Results 182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1-1.4) and rivaroxaban (median 1.3, IQR 1.1-1.6) compared with apixaban (median 1.1, IQR 1.0-1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8-46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal. Discussion Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs. Level of evidence Level IV.
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Affiliation(s)
- Leslie M Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Alexandra Brito
- Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Galinos Barmparas
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Patrick Bosarge
- Division of Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Carlos V Brown
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Marko Bukur
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Surgical Intensive Care Unit Bellevue Hospital Center, New York, USA
| | - Matthew M Carrick
- University of North Texas Health Science Center, Fort Worth, Texas, USA
| | | | - Jan Holly-Nicolas
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Kenji Inaba
- Division of Trauma & Critical Care, University of Southern California, Los Angeles, California, USA
| | - Stephen Kaminski
- Department of General Surgery and Surgical Critical Care, Santa Barbara Cottage Hospital, Santa Barbara, California, USA
| | - Amanda L Klein
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Tammy Kopelman
- Division of Burns, Trauma, and Surgical Critical Care, University of Arizona Medical School-Phoenix Campus, Phoenix, Arizona, USA
| | - Eric J Ley
- Department of General Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Ericca M Martinez
- Chandler Regional Medical Center, Grand Canyon University, Phoenix, Arizona, USA
| | - Forrest O Moore
- Department of General Surgery, Trauma and Surgical Critical Care, Chandler Regional Medical Center, University of Arizona College of Medicine, Chandler, Arizona, USA
| | - Jason Murry
- Department of General Surgery Trauma Services, East Texas Medical Center, Tyler, Texas, USA
| | - Raminder Nirula
- Department of General Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Douglas Paul
- Division of Trauma, Critical Care and Acute Care Surgery, Kettering Medical Center, Kettering, Ohio, USA
| | - Jacob Quick
- Division of Acute Care Surgery, University of Missouri, Columbia, Missouri, USA
| | - Omar Rivera
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, California, USA
| | - Martin Schreiber
- Division of Trauma, Critical Care & Acute Care Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Raul Coimbra
- Department of General Surgery, Riverside University Health System Medical Center, Loma Linda University School of Medicine, Moreno Valley, California, USA
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Yagneswar H, Todd JM, Sharkey LC, Rendahl A, Tart K. Retrospective comparison of standard clotting tests and novel clot waveform parameters in dogs using the turbidimetric ACL-TOP CTS 300 coagulation analyzer. J Vet Diagn Invest 2018; 30:868-877. [PMID: 30204058 DOI: 10.1177/1040638718797386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Clot waveforms are generated by coagulation analyzers, such as the ACL-TOP, that utilize photo-optical turbidimetric methods to measure prothrombin time (PT) and activated partial thromboplastin time (aPTT), which are standard clotting tests (SCTs). Additional quantitative clot waveform analysis (CWA) parameters include maximum velocity of the PT curve (PT1d), maximum acceleration of the aPTT curve (aPTT2d), and their change in optical density (ODdelta). We explored the potential for CWA to contribute unique information compared to SCTs and quantitative fibrinogen assay (QFA) in dogs with clinical indications for laboratory evaluation of coagulation. We retrospectively evaluated the frequency and agreement between normal, high, and low values of CWA and SCTs for 203 dogs relative to reference intervals (RIs). Most dogs had SCTs within RIs, but most CWA values were high regardless of whether SCT values were within, below, or above the RI. Agreement between SCTs and CWA was slight (kappa <30%). Clinically significant bleeding was noted in 28 of 203 (14%) dogs. SCTs were not different between bleeders and non-bleeders. Median QFA, PT1d, aPTTdelta, and aPTT2d values were statistically significantly higher than RIs in non-bleeders compared to bleeders, whose median values were not below RI. Compared with SCTs, CWA identified differences between the 2 groups. However, wide overlap between the 2 groups limits the use of CWA to clinically discriminate between bleeders and non-bleeders in a heterogeneous population of dogs. Further studies on the diagnostic utility of CWA in coagulopathic dogs are needed.
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Affiliation(s)
- Hamsini Yagneswar
- Departments of Veterinary Clinical Sciences (Yagneswar, Tart, Todd, Sharkey), College of Veterinary Medicine, University of Minnesota, St. Paul, MN.,Veterinary and Biomedical Science (Rendahl), College of Veterinary Medicine, University of Minnesota, St. Paul, MN.,Current address: Cummings School of Veterinary Medicine, Tufts University, 200 Westboro Road, N Grafton, MA 01536 (Sharkey)
| | - Jeffrey M Todd
- Departments of Veterinary Clinical Sciences (Yagneswar, Tart, Todd, Sharkey), College of Veterinary Medicine, University of Minnesota, St. Paul, MN.,Veterinary and Biomedical Science (Rendahl), College of Veterinary Medicine, University of Minnesota, St. Paul, MN.,Current address: Cummings School of Veterinary Medicine, Tufts University, 200 Westboro Road, N Grafton, MA 01536 (Sharkey)
| | - Leslie C Sharkey
- Departments of Veterinary Clinical Sciences (Yagneswar, Tart, Todd, Sharkey), College of Veterinary Medicine, University of Minnesota, St. Paul, MN.,Veterinary and Biomedical Science (Rendahl), College of Veterinary Medicine, University of Minnesota, St. Paul, MN.,Current address: Cummings School of Veterinary Medicine, Tufts University, 200 Westboro Road, N Grafton, MA 01536 (Sharkey)
| | - Aaron Rendahl
- Departments of Veterinary Clinical Sciences (Yagneswar, Tart, Todd, Sharkey), College of Veterinary Medicine, University of Minnesota, St. Paul, MN.,Veterinary and Biomedical Science (Rendahl), College of Veterinary Medicine, University of Minnesota, St. Paul, MN.,Current address: Cummings School of Veterinary Medicine, Tufts University, 200 Westboro Road, N Grafton, MA 01536 (Sharkey)
| | - Kelly Tart
- Departments of Veterinary Clinical Sciences (Yagneswar, Tart, Todd, Sharkey), College of Veterinary Medicine, University of Minnesota, St. Paul, MN.,Veterinary and Biomedical Science (Rendahl), College of Veterinary Medicine, University of Minnesota, St. Paul, MN.,Current address: Cummings School of Veterinary Medicine, Tufts University, 200 Westboro Road, N Grafton, MA 01536 (Sharkey)
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Kim JS, Wang IJ, Yeom SR, Cho SJ, Kim JH, Seok JP, Lee SH, Bae BG, Min MK. Usefulness of Rotational Thromboelastometry as a Mortality Predictor of Hyperfibrinolysis in Patients with Severe Trauma. Acute Crit Care 2018; 33:162-169. [PMID: 31723880 PMCID: PMC6786692 DOI: 10.4266/acc.2018.00199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/02/2018] [Accepted: 08/17/2018] [Indexed: 12/30/2022] Open
Abstract
Background Hemorrhage is the major cause of traumatic death and the leading cause of preventable death. Hyperfibrinolysis is associated with trauma severity. Viscoelastic hemostatic assays show complete clot formation dynamics. The present study was designed to identify the relationship between hyperfibrinolysis and mortality, metabolic acidosis, and coagulopathy in patients with trauma. Methods Patients with severe trauma (injury severity score [ISS] of 15 or higher) who were assessed using rotational thromboelastometry (ROTEM) were included in the present study from January 2017 to December 2017. Variables were obtained from the Korea Trauma Database or the medical charts of the patients. To identify whether hyperfibrinolysis is an independent predictor of mortality, univariate and multivariate Cox regression analyses were performed. Results During the 1-year study period, 190 patients were enrolled. In total, 21 (11.1%) had hyperfibrinolysis according to the ROTEM analysis and 46 (24.2%) died. Patients with hyperfibrinolysis had a higher ISS (P=0.014) and mortality rate (P<0.001) than did those without hyperfibrinolysis. In multivariate Cox analysis, hyperfibrinolysis (hazard ratio [HR], 4.960; 95% confidence interval [CI], 2.447 to 10.053), age (HR, 1.033; 95% CI, 1.013 to 1.055), lactic acid level (HR, 1.085; 95% CI, 1.003 to 1.173), and ISS (HR, 1.037; 95% CI, 1.004 to 1.071) were independent predictors of mortality. Conclusions Hyperfibrinolysis is associated with increased mortality, worse metabolic acidosis, and severe coagulopathy and is an independent predictor of mortality in patients with trauma.
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Affiliation(s)
- Ji Soo Kim
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Il Jae Wang
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Seok Ran Yeom
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Suck Ju Cho
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Jae Hun Kim
- Department of Trauma Surgery, Pusan National University Hospital, Busan, Korea
| | - June Pill Seok
- Department of Trauma Surgery, Pusan National University Hospital, Busan, Korea
| | - Seong Hwa Lee
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Byung Gwan Bae
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Mun Ki Min
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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50
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Kelly JM, Rizoli S, Veigas P, Hollands S, Min A. Using rotational thromboelastometry clot firmness at 5 minutes (ROTEM ® EXTEM A5) to predict massive transfusion and in-hospital mortality in trauma: a retrospective analysis of 1146 patients. Anaesthesia 2018; 73:1103-1109. [PMID: 29658985 PMCID: PMC6120456 DOI: 10.1111/anae.14297] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2018] [Indexed: 12/31/2022]
Abstract
Viscoelastic assays such as TEG® and ROTEM® are increasingly used to guide transfusion of blood products. The EXTEM assay maximum clot firmness (MCF) is a ROTEM measure available after 25–29 min used to guide early decisions. EXTEM A10, the clot firmness at 10 min, is an accepted early surrogate, but investigators differ on whether A5, the clot firmness at 5 min, is acceptable. We re‐examined this in a retrospective observational analysis of 1146 trauma patients in one centre who had ROTEM data recorded. A5 and A10 both correlated well with maximum clot firmness, with Pearson coefficients of r = 0.92 and r = 0.96, respectively. The correlations of A5, A10 and maximum clot firmness with requirement for massive transfusion were all similarly high, with c‐stats of 0.87, 0.89 and 0.90, respectively. The correlations with mortality were also similar but weaker, with c‐stats of 0.67, 0.69 and 0.69, respectively. Using a previously validated cut‐off of A5 < 35 mm to predict massive transfusion gave a sensitivity of 95%, specificity 83%, positive predictive value 9.3% and negative predictive value 100%. Using a value of A5 < 29 mm, for a pragmatic positive predictive value of 20%, gave a sensitivity of 67%, specificity 95% and negative predictive value 99%. Whether aiming for a high sensitivity or a strong predictive value, A5 was non‐inferior to A10 and actually missed fewer cases needing massive transfusion. A5 has similar utility to both A10 and maximum clot firmness as an early measure of clot firmness, and a low A5 value is strongly predictive of the need for massive transfusion.
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Affiliation(s)
- J M Kelly
- Department of Anaesthesia and Intensive Care, Queen Elizabeth Hospital, Birmingham, UK
| | - S Rizoli
- Trauma Department, St Michael's Hospital, Toronto, Canada
| | - P Veigas
- Trauma Department, St Michael's Hospital, Toronto, Canada
| | - S Hollands
- Institute for Clinical Evaluative Studies, University of Toronto, Canada
| | - A Min
- Royal College of Surgeons in Ireland, Dublin, Ireland
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