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Getrajdman C, Sison M, Lin HM, Katz D. The impact of crystalloid versus colloid on coagulation as measured by thromboelastometry in term parturients: an in vitro study. J Matern Fetal Neonatal Med 2021; 35:6876-6883. [PMID: 34015981 DOI: 10.1080/14767058.2021.1929157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE A pilot study to examine the impact of crystalloid versus albumin hemodilution in vitro on coagulation using thromboelastometry in pregnant patients. METHODS This prospective, observational pilot study included seventy-six pregnant patients at term (≥37 weeks) without history of bleeding or clotting disorder or on anticoagulation. Blood was collected and diluted with either Plasma-Lyte or albumin at the following levels: 0%, 20%, 25%, 30%, 35%, 40%, 45%, 55%, 60%, 65%, 70%, 75%, 80%. Thromboelastometry was performed to assess for coagulation changes. RESULTS There was a small, statistically significant difference in the FIBTEM A5 between the Plasma-Lyte and albumin samples. However, the predicted probability of coagulopathy, using FIBTEM A5 less than 12 mm, was not different between the groups at any dilution. There was no difference in EXTEM clotting time at low-moderate levels of hemodilution. At dilutions above 40%, the albumin group had a significantly greater prolongation in clotting time compared to the Plasma-Lyte group. CONCLUSION When albumin is used at low-moderate levels of hemodilution in vitro in parturients there is no additional risk of coagulopathy compared to hemodilution with crystalloid. Given that colloids are frequently used to restore intravascular volume during massive hemorrhage, these results support that during early stages of hemorrhage, albumin may not contribute to additional coagulopathy beyond that of hemodilution, although further in vivo studies are needed.
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Affiliation(s)
- Chloe Getrajdman
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthew Sison
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Katz
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Amgalan A, Allen T, Othman M, Ahmadzia HK. Systematic review of viscoelastic testing (TEG/ROTEM) in obstetrics and recommendations from the women's SSC of the ISTH. J Thromb Haemost 2020; 18:1813-1838. [PMID: 32356929 DOI: 10.1111/jth.14882] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/13/2020] [Accepted: 04/24/2020] [Indexed: 12/13/2022]
Abstract
Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are point-of-care viscoelastic devices that use whole blood samples to assess coagulation and fibrinolysis. These devices have been studied extensively in cardiac surgery, but there is limited robust evidence supporting its use in obstetrics. The hesitancy toward its routine use in obstetrics may be due to the current lack of randomized controlled trials and large observational studies. The study aims to systematically review studies that investigated TEG/ROTEM use in pregnancy or peripartum, and to provide recommendations for future studies to fill current research gaps. We performed a systematic review of studies on viscoelastic testing in obstetrics. Included studies were original research, used TEG or ROTEM during pregnancy or peripartum, and published in English. Ninety-three studies, spanning 31 years from 1989 to 2020 and with a total of 32,817 participants, were included. Sixty-two (66.7%) of the studies used TEG and 31 (33.3%) used ROTEM. To date, there are a total of two randomized controlled trials on TEG/ROTEM use in obstetrics. ROTEM may be used to guide transfusion therapy for postpartum hemorrhage. TEG and ROTEM can detect the hypercoagulable changes associated with pregnancy. Variability between study protocols and results suggests the need for future large prospective high-quality studies with standardized protocols to investigate the utility of TEG/ROTEM in assessing risk for thrombosis and hemorrhage as well as in guiding prophylaxis and treatment in obstetric patients. This review identifies the gaps and provides concrete recommendations for future studies to fill those gaps.
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Affiliation(s)
| | - Terrence Allen
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada
| | - Homa K Ahmadzia
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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3
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Mayeza S, Loo L, Dyer R, Arcache M. Coagulation in the HIV-positive pregnant patient : a thromboelastography study. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.4.2374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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4
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Chooi C, Cox JJ, Lumb RS, Middleton P, Chemali M, Emmett RS, Simmons SW, Cyna AM. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Database Syst Rev 2020; 7:CD002251. [PMID: 32619039 PMCID: PMC7387232 DOI: 10.1002/14651858.cd002251.pub4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Maternal hypotension is the most frequent complication of spinal anaesthesia for caesarean section. It can be associated with nausea or vomiting and may pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis, neurological injury). OBJECTIVES To assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (9 August 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials, including full texts and abstracts, comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section. We excluded studies if hypotension was not an outcome measure. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality and extracted data from eligible studies. We report 'Summary of findings' tables using GRADE. MAIN RESULTS We included 125 studies involving 9469 women. Interventions were to prevent maternal hypotension following spinal anaesthesia only, and we excluded any interventions considered active treatment. All the included studies reported the review's primary outcome. Across 49 comparisons, we identified three intervention groups: intravenous fluids, pharmacological interventions, and physical interventions. Authors reported no serious adverse effects with any of the interventions investigated. Most trials reported hypotension requiring intervention and Apgar score of less than 8 at five minutes as the only outcomes. None of the trials included in the comparisons we describe reported admission to neonatal intensive care unit. Crystalloid versus control (no fluids) Fewer women experienced hypotension in the crystalloid group compared with no fluids (average risk ratio (RR) 0.84, 95% confidence interval (CI) 0.72 to 0.98; 370 women; 5 studies; low-quality evidence). There was no clear difference between groups in numbers of women with nausea and vomiting (average RR 0.19, 95% CI 0.01 to 3.91; 1 study; 69 women; very low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (60 babies, low-quality evidence). Colloid versus crystalloid Fewer women experienced hypotension in the colloid group compared with the crystalloid group (average RR 0.69, 95% CI 0.58 to 0.81; 2009 women; 27 studies; very low-quality evidence). There were no clear differences between groups for maternal hypertension requiring intervention (average RR 0.64, 95% CI 0.09 to 4.46, 3 studies, 327 women; very low-quality evidence), maternal bradycardia requiring intervention (average RR 0.98, 95% CI 0.54 to 1.78, 5 studies, 413 women; very low-quality evidence), nausea and/or vomiting (average RR 0.89, 95% CI 0.66 to 1.19, 14 studies, 1058 women, I² = 29%; very low-quality evidence), neonatal acidosis (average RR 0.83, 95% CI 0.15 to 4.52, 6 studies, 678 babies; very low-quality evidence), or Apgar score of less than 8 at five minutes (average RR 0.24, 95% CI 0.03 to 2.05, 10 studies, 730 babies; very low-quality evidence). Ephedrine versus phenylephrine There were no clear differences between ephedrine and phenylephrine groups for preventing maternal hypotension (average RR 0.92, 95% CI 0.71 to 1.18; 401 women; 8 studies; very low-quality evidence) or hypertension (average RR 1.72, 95% CI 0.71 to 4.16, 2 studies, 118 women, low-quality evidence). Rates of bradycardia were lower in the ephedrine group (average RR 0.37, 95% CI 0.21 to 0.64, 5 studies, 304 women, low-quality evidence). There was no clear difference in the number of women with nausea and/or vomiting (average RR 0.76, 95% CI 0.39 to 1.49, 4 studies, 204 women, I² = 37%, very low-quality evidence), or babies with neonatal acidosis (average RR 0.89, 95% CI 0.07 to 12.00, 3 studies, 175 babies, low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (321 babies; low-quality evidence). Ondansetron versus control Ondansetron administration was more effective than control (placebo saline) for preventing hypotension requiring treatment (average RR 0.67, 95% CI 0.54 to 0.83; 740 women, 8 studies, low-quality evidence), bradycardia requiring treatment (average RR 0.49, 95% CI 0.28 to 0.87; 740 women, 8 studies, low-quality evidence), and nausea and/or vomiting (average RR 0.35, 95% CI 0.24 to 0.51; 653 women, 7 studies, low-quality evidence). There was no clear difference between the groups in rates of neonatal acidosis (average RR 0.48, 95% CI 0.05 to 5.09; 134 babies; 2 studies, low-quality evidence) or Apgar scores of less than 8 at five minutes (284 babies, low-quality evidence). Lower limb compression versus control Lower limb compression was more effective than control for preventing hypotension (average RR 0.61, 95% CI 0.47 to 0.78, 11 studies, 705 women, I² = 65%, very low-quality evidence). There was no clear difference between the groups in rates of bradycardia (RR 0.63, 95% CI 0.11 to 3.56, 1 study, 74 women, very low-quality evidence) or nausea and/or vomiting (average RR 0.42, 95% CI 0.14 to 1.27, 4 studies, 276 women, I² = 32%, very-low quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (130 babies, very low-quality evidence). Walking versus lying There was no clear difference between the groups for women with hypotension requiring treatment (RR 0.71, 95% CI 0.41 to 1.21, 1 study, 37 women, very low-quality evidence). Many included studies reported little to no information that would allow an assessment of their risk of bias, limiting our ability to draw meaningful conclusions. GRADE assessments of the quality of evidence ranged from very low to low. We downgraded evidence for limitations in study design, imprecision, and indirectness; most studies assessed only women scheduled for elective caesarean sections. External validity also needs consideration. Readers should question the use of colloids in this context given the serious potential side effects such as allergy and renal failure associated with their administration. AUTHORS' CONCLUSIONS While interventions such as crystalloids, colloids, ephedrine, phenylephrine, ondansetron, or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension in some women. We cannot draw any conclusions regarding rare adverse effects associated with use of the interventions (for example colloids) due to the relatively small numbers of women studied.
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Affiliation(s)
- Cheryl Chooi
- Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
| | - Julia J Cox
- Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
| | - Richard S Lumb
- Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Richard S Emmett
- Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
| | - Scott W Simmons
- Department of Anaesthesia, Mercy Hospital for Women, Heidelberg, Australia
| | - Allan M Cyna
- Department of Women's Anaesthesia, Women's and Children's Hospital, Adelaide, Australia
- University of Sydney, Sydney, Australia
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Managing coagulopathy following PPH. Best Pract Res Clin Obstet Gynaecol 2019; 61:106-120. [DOI: 10.1016/j.bpobgyn.2019.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/01/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022]
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Yoon HJ. Coagulation abnormalities and bleeding in pregnancy: an anesthesiologist's perspective. Anesth Pain Med (Seoul) 2019; 14:371-379. [PMID: 33329765 PMCID: PMC7713810 DOI: 10.17085/apm.2019.14.4.371] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 10/01/2019] [Indexed: 11/25/2022] Open
Abstract
During pregnancy, the procoagulant activity increases (manifested by elevation in factor VII, factor VIII, factor X, and fibrinogen levels), while the anticoagulant activity decreases (characterized by reduction in fibrinolysis and protein S activity), resulting in hypercoagulation. Standard coagulation tests, such as prothrombin time or activated partial thromboplastin time, are still used despite the lack of evidence supporting its accuracy in evaluating the coagulation status of pregnant women. Thromboelastography and rotational thromboelastometry, which are used to assess the function of platelets, soluble coagulation factors, fibrinogen, and fibrinolysis, can replace standard coagulation tests. Platelet count and function and the effect of anticoagulant treatment should be assessed to determine the risk of hematoma associated with regional anesthesia. Moreover, anesthesiologists should monitor patients for postpartum hemorrhage (PPH), and attention should be paid when performing rapid coagulation tests, transfusions, and prohemostatic pharmacotherapy. Transfusion of a high ratio of plasma and platelets to red blood cells (RBCs) showed high hemostasis success and low bleeding-related mortality rates in patients with severe trauma. However, the effects of high ratios of plasma and platelets and the ratio of plasma to RBCs and platelets to RBCs in the treatment of massive PPH were not established. Intravenous tranexamic acid should be administered immediately after the onset of postpartum bleeding. Pre-emptive treatment with fibrinogen for PPH is not effective in reducing bleeding. If fibrinogen levels of less than 2 g/L are identified, 2–4 g of fibrinogen or 5–10 ml/kg cryoprecipitate should be administered.
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Affiliation(s)
- Hea-Jo Yoon
- Department of Anesthesiology and Pain Medicine, Ilsan Jeil Hospital, Goyang, Korea
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Magunia H, Schenk S, Schlensak C, Icheva V, Rosenberger P, Straub A, Nowak-Machen M. Detection of early incomplete heparin reversal following congenital cardiac surgery: A single-center retrospective observational study. Thromb Res 2019; 182:33-38. [DOI: 10.1016/j.thromres.2019.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/09/2019] [Accepted: 08/17/2019] [Indexed: 11/24/2022]
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8
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Riley ET, Mangum K, Carvalho B, Butwick AJ. The Crystalloid Co-Load: Clinically as Effective as Colloid Preload for Preventing Hypotension from Spinal Anaesthesia for Caesarean Delivery. Turk J Anaesthesiol Reanim 2019; 47:35-40. [PMID: 31276109 DOI: 10.5152/tjar.2018.76402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 07/12/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Colloid preloading diminishes post-spinal hypotension. However, whether colloid preloading is superior to crystalloid co-loading is uncertain. In this retrospective study, we compared the effects of a colloid preload versus a crystalloid co-load on vasopressor requirements and maternal haemodynamics among women undergoing elective caesarean delivery (CD) with spinal anaesthesia. Methods We extracted data from the medical records of 160 healthy women who underwent elective CD with spinal anaesthesia at an academic obstetric centre before and after an institutional fluid-loading protocol change. Patients received a 500 mL 6% hydroxyethyl starch preload or a 1000 mL crystalloid co-load. The primary outcome was the total phenylephrine dose administered from spinal block placement to delivery. Results Our cohort comprised 79 women in the colloid group and 77 women in the crystalloid group. The mean phenylephrine use was significantly lower in the colloid group than in the crystalloid group (489±403 μg vs. 647±464 μg, respectively, p=0.02). The maximal drop in systolic blood pressure was greater in the colloid group than in the crystalloid group (36±20 mmHg vs. 29±16 mmHg, respectively, p=0.02). There were no clinically significant differences between the groups in heart rate, blood loss, temperature and Apgar scores. Conclusion Vasopressor use was lower in colloid preloading than in crystalloid co-loading. However, differences in all outcome measures were minimal and likely clinically insignificant, suggesting that both fluid-loading techniques are appropriate to use for the prevention of spinal hypotension in women undergoing CD.
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Affiliation(s)
- Edward T Riley
- Stanford University School of Medicine, 300 Pasteur Drive, Stanford, California, USA
| | - Kevin Mangum
- A.T. Still University School of Osteopathic Medicine in Arizona, Meza, Arizona, USA
| | - Brendan Carvalho
- Stanford University School of Medicine, 300 Pasteur Drive, Stanford, California, USA
| | - Alexander J Butwick
- Stanford University School of Medicine, 300 Pasteur Drive, Stanford, California, USA
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9
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Hill JS, Devenie G, Powell M. Point-of-Care Testing of Coagulation and Fibrinolytic Status during Postpartum Haemorrhage: Developing a Thrombelastography®-Guided Transfusion Algorithm. Anaesth Intensive Care 2019. [DOI: 10.1177/0310057x1204000612] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- J. S. Hill
- Department of Anaesthesia, National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - G. Devenie
- Department of Anaesthesia, National Women's Health, Auckland City Hospital, Auckland, New Zealand
- Operations and Project Administrator, LabPlus, Auckland City Hospital
| | - M. Powell
- Department of Anaesthesia, National Women's Health, Auckland City Hospital, Auckland, New Zealand
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Chooi C, Cox JJ, Lumb RS, Middleton P, Chemali M, Emmett RS, Simmons SW, Cyna AM. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Database Syst Rev 2017; 8:CD002251. [PMID: 28976555 PMCID: PMC6483677 DOI: 10.1002/14651858.cd002251.pub3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Maternal hypotension is the most frequent complication of spinal anaesthesia for caesarean section. It can be associated with nausea or vomiting and may pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis, neurological injury). OBJECTIVES To assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (9 August 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials, including full texts and abstracts, comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section. We excluded studies if hypotension was not an outcome measure. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study quality and extracted data from eligible studies. We report 'Summary of findings' tables using GRADE. MAIN RESULTS We included 126 studies involving 9565 participants. Interventions were to prevent maternal hypotension following spinal anaesthesia only, and we excluded any interventions considered active treatment. All the included studies reported the review's primary outcome. Across 49 comparisons, we identified three intervention groups: intravenous fluids, pharmacological interventions, and physical interventions. Authors reported no serious adverse effects with any of the interventions investigated. Most trials reported hypotension requiring intervention and Apgar score of less than 8 at five minutes as the only outcomes. None of the trials included in the comparisons we describe reported admission to neonatal intensive care unit. Crystalloid versus control (no fluids)Fewer women experienced hypotension in the crystalloid group compared with no fluids (average risk ratio (RR) 0.84, 95% confidence interval (CI) 0.72 to 0.98; 370 women; 5 studies; low-quality evidence). There was no clear difference between groups in numbers of women with nausea and vomiting (average RR 0.19, 95% CI 0.01 to 3.91; 1 study; 69 women; very low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (60 babies, low-quality evidence). Colloid versus crystalloidFewer women experienced hypotension in the colloid group compared with the crystalloid group (average RR 0.68, 95% CI 0.58 to 0.80; 2105 women; 28 studies; very low-quality evidence). There were no clear differences between groups for maternal hypertension requiring intervention (average RR 0.64, 95% CI 0.09 to 4.46, 3 studies, 327 women;very low-quality evidence), maternal bradycardia requiring intervention (average RR 0.99, 95% CI 0.55 to 1.79, 6 studies, 509 women; very low-quality evidence), nausea and/or vomiting (average RR 0.83, 95% CI 0.61 to 1.13, 15 studies, 1154 women, I² = 37%; very low-quality evidence), neonatal acidosis (average RR 0.83, 95% CI 0.15 to 4.52, 6 studies, 678 babies; very low-quality evidence), or Apgar score of less than 8 at five minutes (average RR 0.24, 95% CI 0.03 to 2.05, 11 studies, 826 babies; very low-quality evidence). Ephedrine versus phenylephrineThere were no clear differences between ephedrine and phenylephrine groups for preventing maternal hypotension (average RR 0.92, 95% CI 0.71 to 1.18; 401 women; 8 studies; very low-quality evidence) or hypertension (average RR 1.72, 95% CI 0.71 to 4.16, 2 studies, 118 women, low-quality evidence). Rates of bradycardia were lower in the ephedrine group (average RR 0.37, 95% CI 0.21 to 0.64, 5 studies, 304 women, low-quality evidence). There was no clear difference in the number of women with nausea and/or vomiting (average RR 0.76, 95% CI 0.39 to 1.49, 4 studies, 204 women, I² = 37%, very low-quality evidence), or babies with neonatal acidosis (average RR 0.89, 95% CI 0.07 to 12.00, 3 studies, 175 babies, low-quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (321 babies; low-quality evidence). Ondansetron versus controlOndansetron administration was more effective than control (placebo saline) for preventing hypotension requiring treatment (average RR 0.67, 95% CI 0.54 to 0.83; 740 women, 8 studies, low-quality evidence), bradycardia requiring treatment (average RR 0.49, 95% CI 0.28 to 0.87; 740 women, 8 studies, low-quality evidence), and nausea and/or vomiting (average RR 0.35, 95% CI 0.24 to 0.51; 653 women, 7 studies, low-quality evidence). There was no clear difference between the groups in rates of neonatal acidosis (average RR 0.48, 95% CI 0.05 to 5.09; 134 babies; 2 studies, low-quality evidence) or Apgar scores of less than 8 at five minutes (284 babies, low-quality evidence). Lower limb compression versus controlLower limb compression was more effective than control for preventing hypotension (average RR 0.61, 95% CI 0.47 to 0.78, 11 studies, 705 women, I² = 65%, very low-quality evidence). There was no clear difference between the groups in rates of bradycardia (RR 0.63, 95% CI 0.11 to 3.56, 1 study, 74 women, very low-quality evidence) or nausea and/or vomiting (average RR 0.42 , 95% CI 0.14 to 1.27, 4 studies, 276 women, I² = 32%, very-low quality evidence). No baby had an Apgar score of less than 8 at five minutes in either group (130 babies, very low-quality evidence). Walking versus lyingThere was no clear difference between the groups for women with hypotension requiring treatment (RR 0.71, 95% CI 0.41 to 1.21, 1 study, 37 women, very low-quality evidence).Many included studies reported little to no information that would allow an assessment of their risk of bias, limiting our ability to draw meaningful conclusions. GRADE assessments of the quality of evidence ranged from very low to low. We downgraded evidence for limitations in study design, imprecision, and indirectness; most studies assessed only women scheduled for elective caesarean sections.External validity also needs consideration. Readers should question the use of colloids in this context given the serious potential side effects such as allergy and renal failure associated with their administration. AUTHORS' CONCLUSIONS While interventions such as crystalloids, colloids, ephedrine, phenylephrine, ondansetron, or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension in some women. We cannot draw any conclusions regarding rare adverse effects associated with use of the interventions (for example colloids) due to the relatively small numbers of women studied.
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Affiliation(s)
- Cheryl Chooi
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideAustralia5006
| | - Julia J Cox
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideAustralia5006
| | - Richard S Lumb
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideAustralia5006
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Mark Chemali
- Royal North Shore HospitalReserve RoadSt LeonardsSydneyNSWAustralia2065
| | - Richard S Emmett
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideAustralia5006
| | - Scott W Simmons
- Mercy Hospital for WomenDepartment of Anaesthesia163 Studley RoadHeidelbergVictoriaAustralia3084
| | - Allan M Cyna
- Women's and Children's HospitalDepartment of Women's Anaesthesia72 King William RoadAdelaideAustralia5006
- University of SydneySydneyAustralia
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Terkawi AS, Larkin SK, Tsang S, Sheeran JS, Tiouririne M. Effects of hydroxyethyl starch 6 % (130/0.4) on blood loss during cesarean delivery: a propensity-matched analysis. J Anesth 2016; 30:796-802. [PMID: 27364518 DOI: 10.1007/s00540-016-2208-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/21/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Hydroxyethyl starch is commonly used in the obstetric patient population to prevent hypotension during cesarean delivery. Evidence suggests hetastarch is associated with a dysfunction in coagulation cascade. We hypothesized that hetastarch use to prevent spinal hypotension during cesarean delivery would be associated with an increase in blood loss when compared to crystalloid use. METHODS We performed a retrospective review of patients who underwent elective cesarean delivery under spinal anesthesia at the University of Virginia between 2011 and 2014. Data from 819 patients was used. Blood loss was the primary outcome. Propensity score-matching was used to match patients who received hetastarch (treatment group) with those who did not receive hetastarch (control group). RESULTS Genetic matching resulted in 196 patients in the hetastarch group and 182 patients in the control group. There was no difference in estimated blood loss (p = 0.068), calculated blood loss (p = 0.720), total intraoperative fluid intake (p = 0.289), urine output (p = 0.421), Apgar 1 min (p = 0.830), Apgar 5 min (p = 0.138), phenylephrine consumption (p = 0.742), postoperative day 1 (POD1) hematocrit (p = 0.070) and POD1 platelets (p = 0.233). However, there was a statistically significant difference (but clinically irrelevant) in hematocrit difference between the day of admission and POD1 (mean difference 0.47, p = 0.024), and ephedrine consumption (mean difference 2 mg, p = 0.017) in favor of the control group. CONCLUSIONS Our study did not find an association between increased perioperative blood loss and hetastarch use in patients presenting for elective cesarean delivery.
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Affiliation(s)
- Abdullah S Terkawi
- Department of Anesthesiology, University of Virginia, P.O. Box 800710, Charlottesville, VA, 22908, USA.,Department of Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Sarah K Larkin
- Department of Obstetrics and Gynecology, University of Virginia, P.O. Box 800712, Charlottesville, VA, 22908, USA
| | - Siny Tsang
- Department of Epidemiology, Columbia University, 772 West 168th Street, New York, NY, 10032, USA
| | - Jessica S Sheeran
- Department of Anesthesiology, University of Virginia, P.O. Box 800710, Charlottesville, VA, 22908, USA
| | - Mohamed Tiouririne
- Department of Anesthesiology, University of Virginia, P.O. Box 800710, Charlottesville, VA, 22908, USA.
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Karlsson O, Jeppsson A, Thornemo M, Lafrenz H, Rådström M, Hellgren M. Fibrinogen plasma concentration before delivery is not associated with postpartum haemorrhage: a prospective observational study. Br J Anaesth 2015; 115:99-104. [DOI: 10.1093/bja/aev039] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2014] [Indexed: 02/04/2023] Open
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Impact of 6 % hydroxyethyl starch (HES) 130/0.4 on the correlation between standard laboratory tests and thromboelastography (TEG®) after cardiopulmonary bypass. Thromb Res 2015; 135:984-9. [DOI: 10.1016/j.thromres.2015.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 01/13/2015] [Accepted: 02/04/2015] [Indexed: 10/24/2022]
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Ekelund K, Hanke G, Stensballe J, Wikkelsøe A, Albrechtsen CK, Afshari A. Hemostatic resuscitation in postpartum hemorrhage - a supplement to surgery. Acta Obstet Gynecol Scand 2015; 94:680-692. [PMID: 25660118 DOI: 10.1111/aogs.12607] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 10/14/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Postpartum hemorrhage is a potentially life-threatening albeit preventable condition that persists as a leading cause of maternal death. Identification of safe and cost-effective hemostatic treatment options remains crucial as a supplement to surgery and uterotonic agents. OBJECTIVE This review summarizes the background, current evidence and recommendations with regard to the role of fibrinogen, tranexamic acid, prothrombin complex concentrate, desmopressin, and recombinant factor VIIa in the treatment of patients with postpartum hemorrhage. The benefits and evidence behind traditional standard laboratory tests and viscoelastic hemostatic assays, i.e. thromboelastography TEG(®) and thromboelastometry ROTEM(®) , are discussed. In addition we assess and elaborate on the current paradigm and evidence for transfusion of these patients. DATA SOURCES Publications between 1994 and 2014 were identified from PubMed, EMBASE, Cochrane Library databases, and ClinicalTrial.gov. RESULTS Viscoelastic hemostatic assays were found to provide a real-time continuum of coagulation and fibrinolysis when introduced as a supplement in transfusion management of postpartum hemorrhage. Fibrinogen should be considered when hypofibrinogenemia is identified. Early administration of 1-2 g tranexamic acid is recommended, followed by an additional dose in cases of ongoing bleeding. Uncontrolled hemorrhage requires early balanced transfusion. CONCLUSION Despite the lack of conclusive evidence for optimal hemostatic resuscitation in postpartum hemorrhage, the use of viscoelastic hemostatic assays, fibrinogen, tranexamic acid and balanced transfusion therapy may prove to be potentially pivotal in the treatment of postpartum hemorrhage.
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Affiliation(s)
- Kim Ekelund
- Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Gabriele Hanke
- Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Stensballe
- Department of Anesthesia, Center of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anne Wikkelsøe
- Department of Anesthesiology, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
| | - Charlotte Krebs Albrechtsen
- Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Arash Afshari
- Department of Anesthesia, Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Butwick A, Gutierrez MC, Hilton G. The impact of advanced maternal age on peripartum thromboelastographic coagulation profiles: a prospective observational exploratory study. Can J Anaesth 2014; 62:504-12. [DOI: 10.1007/s12630-014-0300-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 12/09/2014] [Indexed: 11/24/2022] Open
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Ducloy-Bouthors AS, Susen S, Wong CA, Butwick A, Vallet B, Lockhart E. Medical Advances in the Treatment of Postpartum Hemorrhage. Anesth Analg 2014; 119:1140-7. [DOI: 10.1213/ane.0000000000000450] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Long N, Ng S, Donnelly G, Owens M, McNicholas M, McCarthy K, McCaul C. Anatomical characterisation of the cricothyroid membrane in females of childbearing age using computed tomography. Int J Obstet Anesth 2013; 23:10-7. [PMID: 24291169 DOI: 10.1016/j.ijoa.2013.07.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 07/05/2013] [Accepted: 07/06/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND In the event of failure to secure the airway by conventional means, it may be necessary to perform invasive airway access via the cricothyroid membrane. No studies have addressed anatomy of this structure in the obstetric population. We aimed to review the anatomical variation of this structure in a population of childbearing age. METHODS We searched the radiology database for computed tomography studies of the neck performed in a 13-month period in consecutive patients aged 15-55 years. Studies on 18 females and 22 males were reviewed. Male patients were included for comparison. Data were reconstructed using a high spatial frequency algorithm to optimise spatial resolution. Five parameters were measured: distance from the skin to the membrane, maximum midline height of the membrane in the vertical plane, maximum transverse diameter of the membrane, neck diameter and cartilaginous calcification. RESULTS The distance (mean range) from skin to the membrane was similar in females and males (16.2 [3-33] vs. 13.9 [3-37] mm, P = 0.42). The vertical height (9.9 [7-17] vs. 11.4 [8-15] mm, P = 0.04) and maximum width of the membrane (14.5 [10-17] mm vs. 12.5 [10-15] mm, P < 0.01) were greater in males. Cartilaginous calcification was low and did not differ between genders. CONCLUSIONS The cricothyroid membrane is not necessarily a superficial structure and consequently may be difficult to palpate. The smallest dimensions of the membrane indicate that smaller than recommended cricothyroidotomy devices may be required in some patients as the external diameter of commercial trocar devices and tracheal tubes may exceed 7 mm.
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Affiliation(s)
- N Long
- Department of Radiology, The Mater Misericordiae University Hospital, Dublin, Ireland
| | - S Ng
- Department of Anaesthesia, The Rotunda Hospital, Dublin, Ireland
| | - G Donnelly
- Department of Anaesthesia, The Rotunda Hospital, Dublin, Ireland; Department of Anaesthesia, Mater Misericordiae, University Hospital, Dublin, Ireland
| | - M Owens
- Department of Anaesthesia, Mater Misericordiae, University Hospital, Dublin, Ireland
| | - M McNicholas
- Department of Radiology, The Mater Misericordiae University Hospital, Dublin, Ireland
| | - K McCarthy
- Department of Anaesthesia, The Rotunda Hospital, Dublin, Ireland
| | - C McCaul
- Department of Anaesthesia, The Rotunda Hospital, Dublin, Ireland; Department of Anaesthesia, Mater Misericordiae, University Hospital, Dublin, Ireland; School of Medicine and Medical Sciences, University College Dublin, Ireland.
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Sawhney C, Subramanian A, Kaur M, Anjum A, Albert V, Soni KD, Kumar A. Assessment of hemostatic changes after crystalloid and colloid fluid preloading in trauma patients using standard coagulation parameters and thromboelastography. Saudi J Anaesth 2013; 7:48-56. [PMID: 23717233 PMCID: PMC3657925 DOI: 10.4103/1658-354x.109809] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: The choice of an ideal fluid administered post trauma and its subsequent influence on coagulation still poses a clinical dilemma. Hence, this study was designed to assess the influence of in vivo hemodilution with various fluid preparations (4% gelatin, 6% hydoxyethyl starch (HES), Ringer's lactate, 0.9% normal saline) on coagulation using standard coagulation parameters and real-time thromboelastography (TEG) in patients undergoing elective surgery post trauma. Methods: In a randomized, double-blind study, 100 patients of either sex and age, belonging to ASA Grades I and II, scheduled for elective surgeries were allocated into four groups of 25 each according to the type of fluid infused. Group G (4% gelatin), Group N (0.9% normal saline), Group R (Ringer's lactate), and Group H (6% HES) received preloading with 1 L of fluid according to the group. The coagulation status of the patients was assessed during perioperative period (before surgery, after fluid preloading, and at the end of the surgery) using both conventional coagulation analysis and TEG. Statistical Analysis: Analysis of variance (ANOVA), post hoc and Pearson Chi-square test were used. Results: In all the patients preloaded with gelatin, there was a significant increase in prothrombin time index (PTI; 14.88±0.90 vs. 13.78±3.01, P<0.001) and international normalized ratio (INR; 1.12±0.09 vs. 1.09±0.19, P<0.05) compared to the baseline value. An increase was observed in these parameters in the postoperative period also. In the HES group, there was statistically significant increase in PT time (15.70±1.51 vs. 13.74±0.75, P=0.01) and INR (1.20±0.15 vs. 1.03±0.17, P<0.001) as compared to the baseline. In the intergroup comparisons, the patients preloaded with HES had a significant increase in INR (1.20±0.15 vs. 1.12±0.09, P=0.04) and reaction time (R time; 6.84±2.55 min vs. 4.79±1.77 min, P=0.02) as compared to the gelatin group. The fall in coagulation time (k time; 2.16±0.98 vs. 3.94±2.6, P=0.02), rise in maximum amplitude (MA; 61.94±14.08 vs. 50.11±14.10, P=0.04), and rise in A20 (56.17±14.66 vs. 43.11±14.24, P=0.05) were more in patients preloaded with RL as compared to the HES group. 100% patients in the gelatin group, 84.2% patients in the NS group, 94.4% patients in the RL group, and 66.7% patients in the HES group had hypocoagulable (R time > 14 min) state in the postoperative period. Conclusion: Crystalloids are optimal volume expanders in trauma, with RL having beneficial effects on coagulation system (decrease in k time and increase in MA and A20). Among the colloids, HES 6% (130/0.4) affects coagulation parameters (increase in PTI, INR, R time, k time) more than gelatin. Trial registration (protocol number-IEC/NP-189/2011).
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Affiliation(s)
- Chhavi Sawhney
- Department of Anaesthesia and Critical Care, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Li L, Zhang Y, Tan Y, Xu S. Colloid or crystalloid solution on maternal and neonatal hemodynamics for cesarean section: a meta-analysis of randomized controlled trials. J Obstet Gynaecol Res 2013; 39:932-41. [PMID: 23379937 DOI: 10.1111/jog.12001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 09/29/2012] [Indexed: 11/29/2022]
Abstract
AIM To compare the effect of colloid and crystalloid on maternal and neonatal hemodynamics in cesarean section. MATERIAL AND METHODS We searched MEDLINE (PubMed, 1966-2011), EMBASE (1974-2011), http://www.clinicaltrials.gov, the Cochrane Controlled Clinical Trials Register Database, Biosis Preview, and the Chinese Biomedical Database (1980-2011). Randomized controlled trials involving healthy term patients undergoing scheduled cesarean delivery that compared the effect of colloid and crystalloid on hypotension, need for vasopressors, cardiac output, neonatal outcomes, and other adverse effects were analyzed. RESULTS Ten trials of 853 patients were eligible for analysis. When colloid was used, significantly fewer hypotensive events occurred (odds ratio [OR] 3.21, 95% CI 2.15-4.53, number needed to treat = 4), less demand for vasopressors (standard mean difference [SMD] 0.77, 95% CI 0.34-1.21) and improved cardiac output (SMD -1.08, 95% CI -2.00 - -0.17). In subgroup analysis, the use of colloid reduced hypotensive events and adverse effects in Asian patients. CONCLUSION Colloid hydration should be considered first, especially in Asian patients, focusing on dosage and type of fluids. Preventive or therapeutic vasopressors may be required in a significant proportion of patients.
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Affiliation(s)
- Le Li
- Department of Anesthesiology, Zhujiang Hospital, Guangzhou, China
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Fassoulaki A, Staikou C. The impact of spinal anaesthesia for caesarean delivery on coagulation assessed by thromboelastography. Int J Obstet Anesth 2013. [DOI: 10.1016/j.ijoa.2012.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tola G, Sirparo S, Ruggeri L, Capogna G. Thromboelastometry during Labor and after Delivery. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ojanes.2013.34050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Topçu I, Civi M, Oztürk T, Keleş GT, Coban S, Yentür EA, Okçu G. Evaluation of hemostatic changes using n thromboelastography after crystalloid or colloid fluid administration during major orthopedic surgery. Braz J Med Biol Res 2012; 45:869-74. [PMID: 22666779 PMCID: PMC3854317 DOI: 10.1590/s0100-879x2012007500095] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 05/21/2012] [Indexed: 11/27/2022] Open
Abstract
The effects of Ringer lactate, 6% hydroxyethyl starch (130/0.4) or 4% succinylated gelatin solutions on perioperative coagulability were measured by thromboelastography (TEG). Seventy-five patients (ASA I-III) who were to undergo major orthopedic procedures performed under epidural anesthesia were included in the study. Patients were randomly divided into three groups of 25 each for the administration of maintenance fluids: group RL (Ringer lactate), group HES (6% hydroxyethyl starch 130/0.4), and group JEL (4% gelofusine solution). Blood samples were obtained during the perioperative period before epidural anesthesia (t1, baseline), at the end of the surgery (t2), and 24 h after the operation (t3). TEG data, reaction time (R), coagulation time (K), angle value (α), and maximum amplitude (MA) were recorded. TEG parameters changed from normal values in all patients. In group RL, R and K times decreased compared to perioperative values while the α angle and MA increased (P < 0.05). In group HES, R and K times increased, however, the α angle and MA decreased (P < 0.05). In group JEL, R time increased (P < 0.05), but K time, α angle and MA did not change significantly. In the present study, RL, 6% HES (130/0.4) and 4% JEL solutions caused changes in the coagulation system of all patients as measured by TEG, but these changes remained within normal limits.
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Affiliation(s)
- I Topçu
- Department of Anesthesiology and Reanimation, Celal Bayar University, Manisa, Turkey.
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Oh CS, Sung TY, Kim SH, Kim DK, Lim JA, Woo NS. Assessment of coagulation with 6% hydroxyethyl starch 130/0.4 in cesarean section. Korean J Anesthesiol 2012; 62:337-42. [PMID: 22558500 PMCID: PMC3337380 DOI: 10.4097/kjae.2012.62.4.337] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 08/28/2011] [Accepted: 09/02/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Third-generation hydroxyethyl starch (HES) solutions have been developed to minimize negative effects on hemostasis. In normal pregnancy, the coagulation activity increases, reaching a maximum around term. This study examined the effects of hemodilution with HES 130/0.4 (6%) on blood coagulation in parturients in vivo and in vitro. METHODS Forty parturients scheduled for cesarean sections were assigned randomly to receive either 500 or 1,000 ml of HES 130/0.4 (6%). Rotation thromboelastometry (ROTEM®) measurements were performed before and after administering HES 130/0.4 (6%). In addition, blood samples obtained from 20 randomly selected parturients were diluted 10% to 40% using HES 130/0.4 (6%), and ROTEM® measurements were performed before and after dilution. The changes from baseline and the effects of dilution were analyzed by ROTEM® parameters. RESULTS Infusions of 500 or 1,000 ml of HES 130/0.4 (6%) in the parturients altered the clot formation time, α angle, and maximal clot firmness, although all remained within normal ranges. HES 130/0.4 (6%) affected in vitro blood coagulation in parturients' blood containing 10, 20, 30, and 40% HES. The clotting time was prolonged at each dilution percentage, but remained within the normal range. Other parameters showed an impairment of the coagulation system. CONCLUSIONS Blood coagulation in parturients may be compromised at high dilution ratios of HES 130/0.4 (6%) to blood. Nevertheless, the infusion of 1,000 ml of HES 130/0.4 (6%) in normal parturients did not significantly affect blood coagulation.
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Affiliation(s)
- Chung-Sik Oh
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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Macafee B, Campbell JP, Ashpole K, Cox M, Matthey F, Acton L, Yentis SM. Reference ranges for thromboelastography (TEG(®) ) and traditional coagulation tests in term parturients undergoing caesarean section under spinal anaesthesia*. Anaesthesia 2012; 67:741-7. [PMID: 22486761 DOI: 10.1111/j.1365-2044.2012.07101.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
There has been little published work defining 'normal' thromboelastography (TEG(®) ) values in healthy parturients, and few large studies defining reference ranges for traditional coagulation tests in this patient group. Our aim was to establish peri-operative reference ranges for TEG and for standard laboratory coagulation tests in our pregnant population. Fifty healthy term parturients presenting for elective caesarean section under spinal anaesthesia had blood samples taken pre-operatively, on arrival in the recovery room and, in a subset of 33 women, 4 h after routine thromboprophylaxis with enoxaparin 40 mg. All three samples had TEG analysis, the first and second having standard laboratory coagulation tests in addition. Reference ranges for our pregnant population were established, demonstrating a hypercoagulable state in term parturients and a significant effect of enoxaparin. The standard coagulation reference ranges were within 98% of the local non-pregnant ranges. These reference ranges provide a useful comparator for peri-operative TEG and routine coagulation analysis in term parturients.
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Affiliation(s)
- B Macafee
- Chelsea and Westminster Hospital, London, UK.
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Armstrong S, Fernando R, Ashpole K, Simons R, Columb M. Assessment of coagulation in the obstetric population using ROTEM® thromboelastometry. Int J Obstet Anesth 2011; 20:293-8. [DOI: 10.1016/j.ijoa.2011.05.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 05/10/2011] [Accepted: 05/24/2011] [Indexed: 12/22/2022]
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Boyce H, Hume-Smith H, Ng J, Columb M, Stocks G. Use of thromboelastography to guide thromboprophylaxis after caesarean section. Int J Obstet Anesth 2011; 20:213-8. [DOI: 10.1016/j.ijoa.2011.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 03/02/2011] [Accepted: 03/22/2011] [Indexed: 11/26/2022]
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Sertznig C, Vial F, Audibert G, Mertes PM, El Adssi H, Bouaziz H. [Management of hypotension during spinal anaesthesia for elective caesarean section: a survey of practice in Lorraine region]. ACTA ACUST UNITED AC 2011; 30:630-5. [PMID: 21705181 DOI: 10.1016/j.annfar.2011.03.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 03/25/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of the survey was to describe current practice in management of hypotension during spinal anaesthesia for elective caesarean section in Lorraine. STUDY DESIGN Cross-sectional study by a mail survey. METHODS A 20-item postal questionnaire was sent to all anaesthetists working in public or private hospital with a maternity unit in Lorraine. RESULTS The response rate was 65%. Fifty-one percent of the respondents did not have a written procedure for the management of spinal-induced hypotension. Fluid preloading with or without vasopressor was the most common practice. Colloids were used by 20% of the respondents. For prevention of hypotension, 37% used ephedrine, 28% used phenylephrine mostly in association with ephedrine and 9% based their choice on heart rate. Twenty-six percent did not administer any vasopressor to prevent hypotension. First choice vasopressor for treatment of hypotension was ephedrine. Anaesthetists in academic practice were more likely to use coloading and phenylephrine administration, but none of them used colloids for pre- or coloading. CONCLUSION Management of hypotension during spinal anaesthesia for elective caesarean section was significantly influenced by the type of practice.
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Affiliation(s)
- C Sertznig
- Service d'anesthésie-réanimation, maternité régionale universitaire de Nancy, 10, rue du Docteur-Heydenreich, 54000 Nancy, France
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Butwick A, Ting V, Ralls LA, Harter S, Riley E. The association between thromboelastographic parameters and total estimated blood loss in patients undergoing elective cesarean delivery. Anesth Analg 2011; 112:1041-7. [PMID: 21474664 DOI: 10.1213/ane.0b013e318210fc64] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In this study, we assessed the relationship between coagulation parameters using kaolin-activated thromboelastography (TEG®) and total estimated blood loss (EBL) in patients undergoing elective cesarean delivery (CD). METHODS TEG® parameters were recorded in 52 patients before and after elective CD. Laboratory markers of coagulation (prothrombin time, activated partial thromboplastin time, fibrinogen) were also assessed in a smaller subset (21 patients). Correlation and linear regression analysis was used to assess the relationship among TEG® parameters, relevant clinical variables, and total EBL. Secondary analysis included comparisons of TEG® and coagulation profiles pre-CD versus post-CD. RESULTS EBL weakly correlated with percentage change in maximum amplitude (r=0.3; P=0.04) and post-CD maximum rate of thrombus generation (r=0.31; P=0.02). Post-CD values for split point, reaction time, time to maximum rate of thrombin generation, prothrombin time, and activated partial thromboplastin time were significantly increased compared with baseline values (P<0.05). Post-CD α angle, maximum amplitude, total thrombus generation, fibrinogen, and platelet counts were significantly decreased compared with baseline values (P<0.05). CONCLUSIONS There is a weak association between clot strength (as assessed by kaolin-activated TEG®) and EBL in patients undergoing elective CD under neuraxial anesthesia, and a modest reduction in the degree of maternal hypercoagulability occurs in the early postpartum period after elective CD.
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Affiliation(s)
- Alexander Butwick
- Department of Anesthesia (MC: 5640), Stanford University School of Medicine, 300 Pasteur Dr., Stanford, CA 94305, USA.
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Turker G, Yilmazlar T, Mogol EB, Gurbet A, Dizman S, Gunay H. The Effects of Colloid Pre-Loading on Thromboelastography Prior to Caesarean Delivery: Hydroxyethyl Starch 130/0.4 versus Succinylated Gelatine. J Int Med Res 2011; 39:143-9. [DOI: 10.1177/147323001103900115] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This prospective, randomized, double-blind study compared the effects on thromboelastography (TEG) of preloading with two different colloid fluids prior to spinal anaesthesia for caesarean section. Healthy full-term parturients received either 500 ml 6% hydroxyethyl starch 130/0.4 (HES, n = 25) or 500 ml 4% succinylated gelatine (GEL, n = 25) prior to spinal anaesthesia. TEG parameters including reaction time (r-time), clot formation time (k-time), clot formation rate (α-angle) and maximum amplitude (MA) were measured immediately before and after pre-loading. Both groups had significantly shorter r-time and lower MA after pre-loading. The α-angle was significantly decreased after pre-loading with HES but not with GEL. No significant differences in k-time were induced pre-loading. In conclusion, preloading with HES or GEL was associated with a mild hypocoagulable effect in healthy parturients presenting for elective caesarean section; however, all TEG parameters in both groups remained within or very close to the normal range after pre-loading.
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Affiliation(s)
- G Turker
- Department of Anaesthesiology, Uludag University Medical Faculty, Bursa, Turkey
| | - T Yilmazlar
- Department of Anaesthesiology, Uludag University Medical Faculty, Bursa, Turkey
| | - E Basagan Mogol
- Department of Anaesthesiology, Uludag University Medical Faculty, Bursa, Turkey
| | - A Gurbet
- Department of Anaesthesiology, Uludag University Medical Faculty, Bursa, Turkey
| | - S Dizman
- Department of Anaesthesiology, Uludag University Medical Faculty, Bursa, Turkey
| | - H Gunay
- Department of Anaesthesiology, Uludag University Medical Faculty, Bursa, Turkey
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Casutt M, Kristoffy A, Schuepfer G, Spahn DR, Konrad C. Effects on coagulation of balanced (130/0.42) and non-balanced (130/0.4) hydroxyethyl starch or gelatin compared with balanced Ringer’s solution: an in vitro study using two different viscoelastic coagulation tests ROTEM™ and SONOCLOT™ † †Poster presentation at the Annual Meeting of the American Society of Anesthesiologists (ASA) 2008. Br J Anaesth 2010; 105:273-81. [PMID: 20659913 DOI: 10.1093/bja/aeq173] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- M Casutt
- Institute of Anesthesiology and Intensive Care, Kantonsspital Lucerne, Lucerne, Switzerland.
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Abstract
OBJECTIVE To describe the management of severe postpartum hemorrhage. MATERIAL AND METHODS Prospective observational study from July 2005 to November 2007 in women who were admitted to the recovery unit of a tertiary referral hospital due to postpartum hemorrhage. We analyzed incidence, prevalence, morbidity, mortality, and associated risk factors. RESULTS The study included 21,726 deliveries (124 with severe bleeding). Postpartum hemorrhage was more common after an instrumental delivery (odds ratio [OR], 4.54) and after a cesarean delivery (OR, 2.86). The risk factors identified in the study population were multiple gestation pregnancy and fetal death. One patient died due to disseminated intravascular coagulation. The main causes of bleeding were uterine atony (45.2%) followed by vaginal tearing (26.6%). Treatment was provided using packed red blood cells in 96.8% of the patients, fibrinogen in 49.2%, prothrombin complex in 7.25% and activated factor VII in 3.2%. Selective arterial embolization was performed in 10.5% of the cases (success rate, 84.6%) and hysterectomy was required in 13.7%. The main complications were need for postoperative mechanical ventilation (11.3%), myocardial ischemia (4%), pulmonary edema (4.8%), acute renal failure (8.9%), ventricular fibrillation (0.8%), and death (0.8%). CONCLUSIONS The incidence of severe postpartum hemorrhage in patients treated at our hospital is low, as is the mortality rate. Use of fibrinogen is common and provides good results. Angiographic embolization is very effective, though the percentage of hysterectomies is still high. Multiple gestation pregnancy and fetal death are associated risk factors.
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Hetastarch co-loading is as effective as pre-loading for the prevention of hypotension following spinal anesthesia for cesarean delivery. Int J Obstet Anesth 2009; 18:150-5. [DOI: 10.1016/j.ijoa.2008.12.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Revised: 10/25/2008] [Accepted: 12/08/2008] [Indexed: 11/21/2022]
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Abstract
Trauma is responsible for 25% of all emergency department visits causing a healthcare burden of more than $400 billion a year. Timely and appropriate fluid resuscitation may mean the difference between survival and death. Controversy surrounds the best method of fluid resuscitation for optimum recovery. This article will evaluate current research regarding the various types of fluid resuscitation in the trauma population. Colloid and crystalloid fluid will be compared describing the risks and benefits of each.
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Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Database Syst Rev 2006:CD002251. [PMID: 17054153 DOI: 10.1002/14651858.cd002251.pub2] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Maternal hypotension, the most frequent complication of spinal anaesthesia for caesarean section, can be associated with severe nausea or vomiting which can pose serious risks to the mother (unconsciousness, pulmonary aspiration) and baby (hypoxia, acidosis and neurological injury). OBJECTIVES To assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2005). SELECTION CRITERIA Randomised controlled trials comparing interventions to prevent hypotension with placebo or alternative treatment in women having spinal anaesthesia for caesarean section. DATA COLLECTION AND ANALYSIS Three review authors independently assessed eligibility and methodological quality of studies, and extracted data. MAIN RESULTS We included 75 trials (a total of 4624 women). Crystalloids were more effective than no fluids (relative risk (RR) 0.78, 95% confidence interval (CI) 0.60 to 1.00; one trial, 140 women, sequential analysis) and colloids were more effective than crystalloids (RR 0.68, 95% CI 0.52 to 0.89; 11 trials, 698 women) in preventing hypotension following spinal anaesthesia at caesarean section. No differences were detected for different doses, rates or methods of administering colloids or crystalloids. Ephedrine was significantly more effective than control (RR 0.51, 95% CI 0.33 to 0.78; seven trials, 470 women) or crystalloid (RR 0.70, 95% CI 0.50 to 0.96; four trials, 293 women) in preventing hypotension. No significant differences in hypotension were seen between ephedrine and phenylephrine (RR 0.95, 95% CI 0.37 to 2.44; three trials, 97 women) and phenylephrine was more effective than controls (RR 0.27, 95% CI 0.16 to 0.45; two trials, 110 women). High rates or doses of ephedrine may increase hypertension and tachycardia incidence. Lower limb compression was more effective than control (no leg compression) (RR 0.69, 95% CI 0.53 to 0.90; seven trials, 399 women) in preventing hypotension, although different methods of compression appeared to vary in their effectiveness. No other comparisons between different physical methods such as position were shown to be effective, but these trials were often small and thus underpowered to detect true effects should they exist. AUTHORS' CONCLUSIONS While interventions such as colloids, ephedrine, phenylephrine or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension during spinal anaesthesia for caesarean section. No conclusions can be drawn regarding rare adverse effects due to the relatively small numbers of women studied.
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Affiliation(s)
- A M Cyna
- Women's and Children's Hospital, Department of Women's Anaesthesia, 72 King William Road, Adelaide, South Australia, Australia.
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