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Johnson AJ, Rozanski EA, de Laforcade AM, Davila C, Rush JE, Guillaumin J. Viscoelastic coagulation monitoring parameters in cats with acute arterial thromboembolism. J Vet Intern Med 2024; 38:2045-2051. [PMID: 38747192 PMCID: PMC11256171 DOI: 10.1111/jvim.17050] [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: 02/08/2023] [Accepted: 03/08/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Hypercoagulability has been documented in cats with cardiac disease. However, hemostatic parameters, including viscoelastic coagulation monitoring (VCM) have not been reported in cats with arterial thromboembolism (ATE). HYPOTHESIS/OBJECTIVES Compare VCM parameters in cats with acute cardiogenic ATE and in control cats. ANIMALS Sixteen cats with ATE and 30 control cats. METHODS Multicenter university-based prospective study. Cardiogenic ATE was diagnosed based on physical examination and by ultrasonographically-diagnosed left atrial enlargement. Viscoelastic coagulation monitor analysis, CBC, serum biochemistry profile and coagulation profile were performed at admission in cats with ATE. Analysis from healthy control cats was performed using blood collected by direct venipuncture. Our objective was comparison of VCM parameters clot time (CT), clot formation time (CFT), alpha angle (Angle), maximum clot formation (MCF), amplitude at 10 and 20 minutes (A10 and A20, respectively) and clot lysis index at 30 and 45 minutes (LI30 and LI45, respectively) between ATE and control cats. RESULTS Cats with ATE had a decreased angle compared to control cats, with a median (range) of 43° (30-48°) compared to 47° (14-59°; P = .01). The parameters A10, A20 and MCF were decreased in ATE cats compared to control cats with a median (range) of 19 units (8-32) compared to 22 units (6-38), 24.5 units (11-40) compared to 29 units (10-47) and 29.5 units (13-44) compared to 33.5 units (14-53), respectively (P = .01, .01 and .01, respectively). The parameters CT, CFT, LI30 and LI45 were similar between groups (P = .22, .09, .62 and .34, respectively). CONCLUSIONS AND CLINICAL IMPORTANCE Cats with cardiogenic ATE cats have VCM parameters consistent with hypocoagulability compared with healthy cats.
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Affiliation(s)
- Amanda J. Johnson
- Foster Hospital for Small Animals at Tufts Cummings School of Veterinary MedicineNorth GraftonMassachusettsUSA
| | - Elizabeth A. Rozanski
- Foster Hospital for Small Animals at Tufts Cummings School of Veterinary MedicineNorth GraftonMassachusettsUSA
| | - Armelle M. de Laforcade
- Foster Hospital for Small Animals at Tufts Cummings School of Veterinary MedicineNorth GraftonMassachusettsUSA
| | - Claudia Davila
- Foster Hospital for Small Animals at Tufts Cummings School of Veterinary MedicineNorth GraftonMassachusettsUSA
| | - John E. Rush
- Foster Hospital for Small Animals at Tufts Cummings School of Veterinary MedicineNorth GraftonMassachusettsUSA
| | - Julien Guillaumin
- Department of Clinical SciencesColorado State UniversityFort CollinsColoradoUSA
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Chen L, Ding S, Cheng Y, Zhou L, Yan J, Cheng Q, Jin A, Zhou X, Huang H, Hu Y. Application of thromboelastography to predict the severity of bleeding after chimeric antigen receptor (CAR)-T cell therapy in patients with hematological malignancy. Eur J Haematol 2024; 112:257-265. [PMID: 37698159 DOI: 10.1111/ejh.14099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/25/2023] [Accepted: 08/27/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES We aim to analyze the predictive value of thromboelastography on bleeding severity of patients with chimeric antigen receptor (CAR)-T cell therapy. METHODS A total of 80 patients with refractory/relapsed hematological malignancy were enrolled and divided into two groups: the severe bleeding group and the non-severe bleeding group. The thromboelastography data was collected on the day of CAR-T infusion and the 3rd, 7th, 10th, 13th, 17th, and 20th day after CAR-T cell infusion. RESULTS The patients of the severe bleeding group had lower platelet (p < .007), maximum amplitude (p = .002), coagulation index (p = .005), and longer coagulation time (p = .019). Increasing trend in reaction time and coagulation time and decreasing trend in Alpha, maximum amplitude, and coagulation index on Days 0-10, opposite on Days 10-20. Univariate logistic regression analysis and multivariable logistic regression analysis showed maximum amplitude on the 3rd day after CAR-T cell infusion (MA3) (OR = 0.9; 95% CI = 0.84-0.95; p < .001) and cytokine release syndrome grade (OR = 2.57; 95% CI = 1.35-5.32; p = .006) were significantly associated with high bleeding severity. CONCLUSIONS Thromboelastography was considered to be a good predictor of bleeding severity.
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Affiliation(s)
- Liu Chen
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuyi Ding
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yin Cheng
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Linghui Zhou
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Jiali Yan
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qiong Cheng
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Aiyun Jin
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoyu Zhou
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - He Huang
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yongxian Hu
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
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Zhu C, Hou Z, Zhu R, Zhou B, Sun Y, Li Z, Li X, Ding R, Luan Z, Liang Y, Wang L, Ma X. Comparisons of coagulation characteristics between elderly and non-elderly patients with sepsis: A prospective study. Surgery 2023; 173:1303-1310. [PMID: 36774318 DOI: 10.1016/j.surg.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 12/11/2022] [Accepted: 01/06/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND A blunt host defense response in older patients may contribute to different coagulation responses during sepsis. We aimed to investigate the differences in coagulation parameters between elderly and non-elderly patients with sepsis. METHODS Adult patients diagnosed with sepsis within 24 hours after admission to the intensive care unit between September 2018 and December 2020 were prospectively enrolled. Patients were categorized into the adult (18-64 years) and elderly (age ≥65 years) groups. Conventional coagulation parameters and inflammatory markers were measured on intensive care unit admission and on Days 3 and 7. Thromboelastography was performed on intensive care unit admission. The differences in the coagulation parameters between the 2 groups were evaluated. The adult and elderly patients were matched to adjust for baseline characteristics. Correlations between inflammatory markers and coagulation-related parameters were also analyzed. RESULTS Of the 567 patients, 303 (53.4%) were elderly. Compared with adult patients, elderly patients had lower prothrombin time elevation, lower fibrinogen, D-dimer, and fibrin/Fib degradation product levels, and lower proportion of disseminated intravascular coagulation on intensive care unit admission; and, they had lower dynamic platelet, lower fibrinogen, and D-dimer levels during the first week in the intensive care unit. Thromboelastography parameters were generally within the normal range, although elderly patients had lower R and K values and a higher alpha angle. Comparisons of coagulation parameters between the 2 groups revealed similar results in the matched cohort. The inflammatory markers correlated with prothrombin time, activated partial thromboplastin time, and antithrombin III. CONCLUSION Elderly patients had milder coagulation activation, accompanied by a decreased inflammatory response during sepsis, compared to non-elderly patients.
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Affiliation(s)
- Chengrui Zhu
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Zhenzhen Hou
- Department of Surgical Intensive Care Unit, Beijing Chaoyang Hospital Affiliated to Capital Medical University, China
| | - Ran Zhu
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Baosen Zhou
- Department of Clinical Epidemiology, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yini Sun
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Zhiliang Li
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xu Li
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Renyu Ding
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Zhenggang Luan
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Yingjian Liang
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Liang Wang
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, The First Hospital of China Medical University, Shenyang, Liaoning Province, China.
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Coagulation Disorders in Sepsis and COVID-19-Two Sides of the Same Coin? A Review of Inflammation-Coagulation Crosstalk in Bacterial Sepsis and COVID-19. J Clin Med 2023; 12:jcm12020601. [PMID: 36675530 PMCID: PMC9866352 DOI: 10.3390/jcm12020601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/27/2022] [Accepted: 01/10/2023] [Indexed: 01/15/2023] Open
Abstract
Sepsis is a major cause of morbidity and mortality worldwide. Sepsis-associated coagulation disorders are involved in the pathogenesis of multiorgan failure and lead to a subsequently worsening prognosis. Alongside the global impact of the COVID-19 pandemic, a great number of research papers have focused on SARS-CoV-2 pathogenesis and treatment. Significant progress has been made in this regard and coagulation disturbances were once again found to underlie some of the most serious adverse outcomes of SARS-CoV-2 infection, such as acute lung injury and multiorgan dysfunction. In the attempt of untangling the mechanisms behind COVID-19-associated coagulopathy (CAC), a series of similarities with sepsis-induced coagulopathy (SIC) became apparent. Whether they are, in fact, the same disease has not been established yet. The clinical picture of CAC shows the unique feature of an initial phase of intravascular coagulation confined to the respiratory system. Only later on, patients can develop a clinically significant form of systemic coagulopathy, possibly with a consumptive pattern, but, unlike SIC, it is not a key feature. Deepening our understanding of CAC pathogenesis has to remain a major goal for the research community, in order to design and validate accurate definitions and classification criteria.
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Chen Y, Chen W, Ba F, Zheng Y, Zhou Y, Shi W, Li J, Yang Z, Mao E, Chen E, Chen Y. Prognostic Accuracy of the Different Scoring Systems for Assessing Coagulopathy in Sepsis: A Retrospective Study. Clin Appl Thromb Hemost 2023; 29:10760296231207630. [PMID: 37920943 PMCID: PMC10623916 DOI: 10.1177/10760296231207630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 11/04/2023] Open
Abstract
There is no gold standard for the diagnosis of coagulation dysfunction in sepsis, and the use of the current scoring systems is still controversial. The purpose of this study was to assess the performance of sepsis-induced coagulopathy (SIC), the Japanese Association for Acute Medicine Disseminated Intravascular Coagulation (JAAM DIC), and the International Society on Thrombosis and Haemostasis overt DIC (ISTH overt-DIC). The relationship between each scoring system and 28-day all-cause mortality was examined. Among 452 patients (mean age, 65 [48,76] years), 306 [66.7%] were men, the median SOFA score was 6 [4,9], and the median APACHE II score was 15 [11,22]. A total of 132 patients (29.2%) died within 28 days. Both the diagnosis of SIC (AUROC, 0.779 [95% CI, 0.728-0.830], P < 0.001) and ISTH overt-DIC (AUROC, 0.782 [95% CI, 0.732-0.833], P < 0.001) performed equally well in the discrimination of 28-day all-cause mortality (between-group difference: SIC versus ISTH overt-DIC, -0.003 [95% CI, -0.025-0.018], P = 0.766). However, the SIC demonstrated greater calibration for 28-day all-cause mortality than ISTH overt-DIC (the coincidence of the calibration curve of the former is higher than that of the latter). The diagnosis of JAAM DIC was not independently associated with 28-day all-cause mortality in sepsis (RR, 1.115, [95% CI 0.660-1.182], P = 0.684). The SIC scoring system demonstrated superior prognostic prediction ability in comparison with the others and is the most appropriate standard for diagnosing coagulopathy in sepsis.
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Affiliation(s)
- Yuwei Chen
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Emergency, the First Hospital of Handan, Handan, China
| | - Weiwei Chen
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fuhua Ba
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanjun Zheng
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Zhou
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen Shi
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Li
- Clinical Research Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhitao Yang
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Enqiang Mao
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Erzhen Chen
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Chen
- Department of Emergency, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Guo X, Shuai XY, Cai TT, Wu ZY, Wu DW, Ding SF. The thrombodynamic ratio as a predictor of 28-day mortality in sepsis patients. Clin Chim Acta 2022; 531:399-405. [PMID: 35483443 DOI: 10.1016/j.cca.2022.04.994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 04/03/2022] [Accepted: 04/21/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The thrombodynamic ratio (TDR) as a composite thromboelastography (TEG) parameter, has been proven to be valuable in multiple diseases. However, the association between TDR and mortality in sepsis has not been studied. METHODS One hundred forty-one patients were enrolled in this retrospectively study. TEG was performed immediately at admission. Two cox proportional hazards models were developed for the prediction of 28-day mortality. The C statistic, continuous net reclassification index (cNRI) and integrated discriminatory index (IDI) were calculated to compare the discrimination performance of clinical models with and without the TDR value. The integrated calibration index (ICI) and E50 were calculated to compare the calibration. RESULTS Patients with lower TDR were more likely to have organ impairments and increased 28-day mortality. The TDR value improved discrimination performance in both Model 1 (C statistic, 0.745 vs 0.735; cNRI 19.4%, p =0.044; IDI 5.6%, p =0.012) and Model 2 (C statistic, 0.761 vs 0.751; IDI, 5.1%, p = 0.012). Compared to the calibration curve of Model 1 without TDR, addition of TDR displayed better calibration (ICI, 0.023; E50, 0.021). CONCLUSION TDR value significantly predicts 28-day mortality in patients with sepsis and could improve the discrimination and calibration performance of clinical prediction models.
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Affiliation(s)
- Xi Guo
- Departments of Critical Care Medicine, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, 266035, China.
| | - Xin-Yan Shuai
- Department of Radiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, 266035, China
| | - Tian-Tian Cai
- Departments of Critical Care Medicine, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, 266035, China
| | - Zhi-Yang Wu
- Departments of Critical Care Medicine, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, 266035, China
| | - Da-Wei Wu
- Departments of Critical Care Medicine, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, Shandong, 266035, China
| | - Shi-Fang Ding
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, Shandong University, Jinan, Shandong, 250012, China.
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Li D, Liu X, Chai Y, Shan J, Xie Y, Liang Y, Huang S, Zheng W, Li Z. Point-of-care blood coagulation assay enabled by printed circuit board-based digital microfluidics. LAB ON A CHIP 2022; 22:709-716. [PMID: 35050293 DOI: 10.1039/d1lc00981h] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The monitoring of coagulation function has great implications in many clinical settings. However, existing coagulation assays are simplex, sample-consuming, and slow in turnaround, making them less suitable for point-of-care testing. In this work, we developed a novel blood coagulation assay that simultaneously assesses both the tendency of clotting and the stiffness of the resultant clot using printed circuit board (PCB)-based digital microfluidics. A drop of blood was actuated to move back and forth on the PCB electrode array, until the motion winded down as the blood coagulated and became thicker. The velocity tracing and the deformation of the clot were calculated via image analysis to reflect the coagulation progression and the clot stiffness, respectively. We investigated the effect of different hardware and biochemical settings on the assay results. To validate the assay, we performed assays on blood samples with hypo- and hyper-coagulability, and the results confirmed the assay's capability in distinguishing different blood samples. We then examined the correlation between the measured metrics in our assays and standard coagulation assays, namely prothrombin time and fibrinogen level, and the high correlation supported the clinical relevance of our assay. We envision that this method would serve as a powerful point-of-care coagulation testing method.
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Affiliation(s)
- Donghao Li
- Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China.
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China
| | - Xinyu Liu
- Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China.
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China
- Faculty of Information Technology, Collaborative Laboratory for Intelligent Science and Systems and State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Macao 999078, China
| | - Yujuan Chai
- Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China.
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China
| | - Jieying Shan
- Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China.
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China
| | - Yihan Xie
- Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China.
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China
| | - Yong Liang
- Faculty of Information Technology, Collaborative Laboratory for Intelligent Science and Systems and State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Macao 999078, China
| | - Susu Huang
- Department of Laboratory Medicine, Shenzhen University General Hospital, Shenzhen 518055, China
| | - Weidong Zheng
- Department of Laboratory Medicine, Shenzhen University General Hospital, Shenzhen 518055, China
| | - Zida Li
- Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China.
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, Department of Biomedical Engineering, School of Medicine, Shenzhen University, Shenzhen 518060, China
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Which Septic Shock Patients With Non-Overt DIC Progress to DIC After Admission? Point-of-Care Thromboelastography Testing. Shock 2022; 57:168-174. [PMID: 35025842 DOI: 10.1097/shk.0000000000001847] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Disseminated intravascular coagulation (DIC) is a life-threatening complication of septic shock; however, risk factors for its development after admission are unknown. Thromboelastography (TEG) can reflect coagulation disturbances in early non-overt DIC that are not detected by standard coagulation tests. This study investigated the risk factors including TEG findings as early predictors for DIC development after admission in septic shock patients with non-overt DIC. METHODS This retrospective observation study included 295 consecutive septic shock patients with non-overt DIC at admission between January 2016 and December 2019. DIC was defined as an International Society on Thrombosis and Hemostasis (ISTH) score ≥ 5. The primary outcome was non-overt DIC at admission that met the ISTH DIC criteria within 3 days after admission. RESULTS Of the 295 patients with non-overt DIC, 89 (30.2%) developed DIC after admission. The DIC group showed a higher ISTH score and 28-day mortality rate than the non-DIC group (2 vs. 3, P < 0.001; 13.6% vs. 27.0%, P = 0.008, respectively). The DIC rate increased with the ISTH score (7.7%, 13.3%, 15.8%, 36.5%, and 61.4% for scores of 0, 1, 2, 3, and 4, respectively). Among TEG values, the maximum amplitude (MA) was higher in the non-DIC group (P < 0.001). On multivariate analysis, an MA < 64 mm was independently associated with DIC development (odds ratio, 2.311; 95% confidence interval, 1.298-4.115). CONCLUSIONS DIC more often developed among those with admission ISTH scores ≥ 3 and was associated with higher mortality rates. An MA < 64 mm was independently associated with DIC development in septic shock patients.
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Zhang T, Li G, Duan M, Lv T, Feng D, Lu N, Zhou Y, Gu L, Zhu W, Gong J. Perioperative parenteral fish oil supplementation improves postoperative coagulation function and outcomes in patients undergoing colectomy for ulcerative colitis. JPEN J Parenter Enteral Nutr 2021; 46:878-886. [PMID: 34609004 DOI: 10.1002/jpen.2269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Ulcerative colitis (UC) is an independent risk factor for thromboembolism, especially during the perioperative period. This study aimed to determine the effects of perioperative parenteral nutrition (PN) supplemented with fish oil (FO) on coagulation function and postoperative outcomes in patients with UC. METHODS This retrospective cohort included 92 consecutive patients who underwent colectomy for UC. Postoperative coagulation indices and outcomes, including thromboelastography (TEG) findings and comprehensive complication index (CCI), were compared. The relative change in serum D-dimer (ΔD-dimer) levels and maximal amplitude (ΔMA) on TEG were also determined. RESULTS Patients receiving PN supplemented with FO (n = 48) had lower D-dimer (P = .036) levels on postoperative day (POD) 5 and a higher MA (P < 0.001) on POD 1 than those who did not receive it (n = 44). A lower ΔD-dimer level (P = .048) and ΔMA (P < 0.001) were also observed in patients receiving FO. The incidence of major postoperative complications (6.3 vs 22.7%; P = .017) and CCI (20.9 vs 23.4%; P = .044) were significantly lower in patients receiving FO. In multivariate analysis, FO (odds ratio, 0.231; 95% confidence interval, 0.055-0.971; P = .046) was a positive protector of major postoperative complications. CONCLUSION Perioperative PN supplemented with FO improved coagulation function and reduced major postoperative complications in patients with UC requiring colectomy. These results may provide cues in formulating management strategies for preventing thromboembolisms and postoperative complications in patients with UC.
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Affiliation(s)
- Tenghui Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Guangke Li
- Department of General Surgery, Jinling Hospital, Nanjing, China
| | - Ming Duan
- Department of General Surgery, Jinling Hospital, Nanjing, China
| | - Tengfei Lv
- Department of General Surgery, Jinling Hospital, Nanjing, China
| | - Dengyu Feng
- Department of General Surgery, Jinling Hospital, Nanjing, China
| | - Nan Lu
- Department of General Surgery, Jinling Hospital, Nanjing, China
| | - Yan Zhou
- Department of General Surgery, Jinling Hospital, Nanjing, China
| | - Lili Gu
- Department of General Surgery, Jinling Hospital, Nanjing, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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10
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Ninan K F, Iyadurai R, Varghese JK, Geevar T, Nair SC, Yadav B, Carey RAB, Sadiq J M, Koshy M, Ralph R, Peter JV. Thromboelastograph:A prognostic marker in sepsis with organ dysfunction without overt bleeding. J Crit Care 2021; 65:177-183. [PMID: 34171693 DOI: 10.1016/j.jcrc.2021.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/08/2021] [Accepted: 06/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Coagulation abnormalities are not infrequent in sepsis. It is unclear if abnormalities in thromboelastogram (TEG) are associated with mortality in patients with severe sepsis without overt bleeding. MATERIALS AND METHODS In this prospective study, patients were categorised as those with normal coagulation, hypercoagulable or hypercoagulable state based on admission TEG parameters (R time, K time, Maximum amplitude (MA), α angle). Their association with mortality was explored using Fisher's exact and Mann-Whitney U test as appropriate. RESULTS The study cohort (n = 87; 49 male) with median (IQR) age 51 (42-60) years and admission SOFA score 8 (6-11) included scrub typhus (24.1%), pneumonia (22.6%) and urosepsis (10.3%). Non-invasive and invasive ventilation and vasopressors were required in 28.1%, 68.9% and 74%, respectively. Mortality was 24.1%. Based on R time, K time and α angle, 3.5% to 9.3% had a hypercoagulable state and 26.7 to 29.9% were hypocoagulable. Prolonged R time (p = 0.04) and reduced alpha angle (p = 0.01) in patients with hypocoagulable state was associated with mortality. K time, α angle and MA were significantly different in patients requiring transfusion (p < 0.001). CONCLUSION A subset of patients with severe sepsis without overt bleeding are hypocoagulable. Hypocoagulability is associated with mortality and need for transfusion.
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Affiliation(s)
- Fibi Ninan K
- Department of Medicine, Christian Medical College (CMC), Vellore, India.
| | - Ramya Iyadurai
- Department of Medicine, Christian Medical College (CMC), Vellore, India
| | | | - Tulasi Geevar
- Department of Transfusion Medicine and Immunohematology, CMC, Vellore, India
| | - Sukesh C Nair
- Department of Transfusion Medicine and Immunohematology, CMC, Vellore, India
| | - Bijesh Yadav
- Department of Biostatistics, CMC, Vellore, India
| | | | - Mohammad Sadiq J
- Department of Medicine, Christian Medical College (CMC), Vellore, India
| | - Maria Koshy
- Department of Medicine, Christian Medical College (CMC), Vellore, India
| | - Ravikar Ralph
- Department of Medicine, Christian Medical College (CMC), Vellore, India
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11
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Luo C, Hu H, Gong J, Zhou Y, Chen Z, Cai S. The Value of Thromboelastography in the Diagnosis of Sepsis-Induced Coagulopathy. Clin Appl Thromb Hemost 2021; 26:1076029620951847. [PMID: 32870718 PMCID: PMC7469719 DOI: 10.1177/1076029620951847] [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: 11/15/2022] Open
Abstract
Thromboelastography (TEG) is regularly used for monitoring abnormalities of the coagulation system in patients with sepsis. However, it is unclear whether TEG parameters are associated with sepsis-induced coagulopathy (SIC). Thus, we aimed to assess the diagnostic value of TEG for SIC. The medical records of patients who underwent TEG from January 2016 to December 2016 were analyzed retrospectively. The patients were divided into sepsis group and non-sepsis group. Baseline patient characteristics and coagulation function indexes were compared. Receiver–operating characteristic curve analysis was used to determine predictors of SIC. A total of 167 patients were included, of whom 84 had sepsis. The clot formation speed (K) was significantly higher(P < 0.001), and the maximum amplitude (MA) and angle were significantly lower (both P < 0.001) in the sepsis group than that in non-sepsis group. Patients with SIC had higher Sepsis-related Organ Failure Assessment scores than those patients without SIC (P < 0.001). The area under the curve of K for diagnosing SIC was 0.910. The area under the curve of angle and MA for excluding SIC was 0.895 and 0.882, respectively. Thus, TEG parameters have good diagnostic value for SIC.
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Affiliation(s)
- Cuizhu Luo
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Department of Critical Care Medicine, Jiang Xi Ping Xiang People's Hospital, Pingxiang Economic and Technological Development District, Ping Xiang, Jiang Xi, China
| | - Hongbin Hu
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jian Gong
- Department of Critical Care Medicine, The Third People' Hospital of Long Gang Distric, Shenzhen, China
| | - Yun Zhou
- Department of Critical Care Medicine, Jiang Xi Ping Xiang People's Hospital, Pingxiang Economic and Technological Development District, Ping Xiang, Jiang Xi, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Shumin Cai
- Department of Critical Care Medicine, 198153Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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12
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Kim SM, Kim SI, Yu G, Kim JS, Hong SI, Kim WY. Hypercoagulability in Septic Shock Patients With Thrombocytopenia. J Intensive Care Med 2021; 37:721-727. [PMID: 34105409 DOI: 10.1177/08850666211024188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite thrombocytopenia, patients with sepsis often experience hypercoagulability. However, limited information is available on the prevalence and effect of hypercoagulability in patients with sepsis-induced thrombocytopenia. Hence, we evaluated the prevalence of hypercoagulability and the association between hypercoagulability and clinical outcomes in septic shock patients with thrombocytopenia. METHODS Thromboelastography (TEG) was performed prospectively in 1294 patients with septic shock at the emergency department (ED) between January 2016 and December 2019. After excluding 405 patients who did not require resuscitation, refused enrollment, or developed septic shock after ED presentation, 889 patients were included. We defined thrombocytopenia as an admission platelet count lower than 150,000/µl according to SOFA score. We defined hypocoagulability and hypercoagulability as coagulation index (CI)< -3 and >3 on TEG, respectively. RESULTS Of the 889 septic shock patients (mean age 65.6 ± 12.7 years, 58.6% male), 473 (53.2%) had thrombocytopenia. Eighty-five (18.0%) patients showed hypercoagulable TEG and73 (15.4%) patients showed hypocoagulable TEG. The hypercoagulable TEG group had a significantly higher fibrinogen level and a lower 28-day mortality rate than the normal and hypocoagulable TEG groups (518 vs. 347 and 315 mg/dL; 7.1% vs. 21.1% and 36.8%, P < 0.01, respectively). In multivariate analysis, hypercoagulable TEG was associated with a decreased mortality rate (odds ratio: 0.395; 95% confidence interval, 0.162-0.965). CONCLUSIONS In septic shock patients with thrombocytopenia, hypercoagulability was not uncommon. TEG can quickly distinguish the hypercoagulability and hypocoagulability states and serve as a valuable tool for evaluating the degree and risk in septic shock patients with thrombocytopenia.
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Affiliation(s)
- Sang-Min Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sang-Il Kim
- Department of Emergency Medicine, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Gina Yu
- Department of Emergency Medicine, University of Yonsei College of Medicine, Seoul, Republic of Korea
| | - June-Sung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Seok In Hong
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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13
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Role of thromboelastography in the evaluation of septic shock patients with normal prothrombin time and activated partial thromboplastin time. Sci Rep 2021; 11:11833. [PMID: 34088928 PMCID: PMC8178375 DOI: 10.1038/s41598-021-91221-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/24/2021] [Indexed: 02/06/2023] Open
Abstract
Coagulopathy is frequent in septic shock and plays a key role in multiple organ dysfunction. The aim of this study is to investigate application values of thromboelastography (TEG) for outcome in septic shock patients with a normal value of prothrombin time (PT) and active partial thromboplastin time (aPTT). Prospective observational study using 1298 consecutive septic shock patients with TEG at admission was conducted at the emergency department (ED) of a tertiary care hospital in South Korea between 2016 and 2019. After excluding overt-disseminated intravascular coagulation (DIC) defined by scoring system, we included patients with a normal value of international normalized ratio ≤ 1.3 and aPTT ≤ 34 s. The primary outcome was 28-day mortality. 893 patients were included and 129 patients with overt DIC were excluded. Of the 764 remaining patients, 414 (54.2%) patients showed normal PT and aPTT (28-day mortality rate, 11.4%). TEG values such as reaction time, kinetic time (K), alpha angle (α), maximum amplitude (MA) and lysis index (LY 30) showed no significant mean difference between the survivor and non-survivor groups. However, hypocoagulable TEG values such as α < 53° (12.0% vs. 23.4%; p = 0.039), and MA < 50 mm (6.3% vs. 21.3%; p = 0.002) were significantly higher in the non-survived group. In multivariate analysis, hypocoagulable state (defined as K > 3 and α < 53 and MA < 50) was independent factors associated with increased risk of death (OR 4.882 [95% CI, 1.698–14.035]; p = 0.003). In conclusion, septic shock patients with normal PT and aPTT can be associated with impaired TEG profile, such as hypocoagulability, associated with increased mortality.
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14
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Hu YL, McRae HL, Refaai MA. Efficacy of viscoelastic hemostatic assay testing in patients with sepsis-induced disseminated intravascular coagulation. Eur J Haematol 2021; 106:873-875. [PMID: 33682140 DOI: 10.1111/ejh.13617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Yue Lin Hu
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, University of Rochester Medical Center, Rochester, NY, USA
| | - Hannah L McRae
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, University of Rochester Medical Center, Rochester, NY, USA
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, University of Rochester Medical Center, Rochester, NY, USA
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15
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Abstract
Hemostatic derangement is a hallmark in severe COVID-19. Markedly elevation of D-dimer and fibrinogen degradation product levels were observed in patients with severe COVID-19 higher and 71.4% of nonsurvivors met the International Society of Thrombosis and Haemostasis criteria of disseminated intravascular coagulation (DIC). Although the clinical and epidemiological features of COVID-19 have been well-described, the underlying mechanism influencing disease severity remains to be elucidated. Herein, the aim of this review article is to evaluate hemostasis in the pathogenesis of COVID-19 and its role in the management of this unprecedented pandemic.
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Affiliation(s)
- Ka U Lio
- Medical student, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Parth Rali
- Division of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
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16
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Adelborg K, Larsen JB, Hvas AM. Disseminated intravascular coagulation: epidemiology, biomarkers, and management. Br J Haematol 2021; 192:803-818. [PMID: 33555051 DOI: 10.1111/bjh.17172] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Disseminated intravascular coagulation (DIC) is a systemic activation of the coagulation system, which results in microvascular thrombosis and, simultaneously, potentially life-threatening haemorrhage attributed to consumption of platelets and coagulation factors. Underlying conditions, e.g. infection, cancer, or obstetrical complications are responsible for the initiation and propagation of the DIC process. This review provides insights into the epidemiology of DIC and the current understanding of its pathophysiology. It details the use of diagnostic biomarkers, current diagnostic recommendations from international medical societies, and it provides an overview of emerging diagnostic and prognostic biomarkers. Last, it provides guidance on management. It is concluded that timely and accurate diagnosis of DIC and its underlying condition is essential for the prognosis. Treatment should primarily focus on the underlying cause of DIC and supportive treatment should be individualised according to the underlying aetiology, patient's symptoms and laboratory records.
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Affiliation(s)
- Kasper Adelborg
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
| | - Julie B Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Denmark
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17
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Role of Thromboelastography as an Early Predictor of Disseminated Intravascular Coagulation in Patients with Septic Shock. J Clin Med 2020; 9:jcm9123883. [PMID: 33260354 PMCID: PMC7760761 DOI: 10.3390/jcm9123883] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 02/03/2023] Open
Abstract
(1) Background: The currently proposed criteria for diagnosing overt disseminated intravascular coagulation (DIC) are not suitable for early detection of DIC. Thromboelastography (TEG) rapidly provides a comprehensive assessment of the entire coagulation process and is helpful as a guide for correcting consumptive coagulopathy in sepsis-induced DIC. This study aimed to investigate the role of TEG in the prediction of DIC in patients with septic shock. (2) Methods: TEG was conducted prospectively in 1294 patients with septic shock at the emergency department (ED) between January 2016 and December 2019. After exclusion of 405 patients with “do not attempt resuscitation” orders, those refusing enrollment, and those developing septic shock after ED presentation, 889 patients were included. DIC was defined as an International Society on Thrombosis and Hemostasis score ≥ 5 points within 24 h. (3) Results: Of the 889 patients with septic shock (mean age 65.6 ± 12.7 years, 58.6% male), 158 (17.8%) developed DIC. TEG values, except lysis after 30 min, were significantly different between the DIC and non-DIC groups. Among the TEG values, the maximal amplitude (MA) had the highest discriminating power for DIC, with an area under the curve of 0.814. An MA < 60 indicated DIC with 79% sensitivity, 73% specificity, and 94% negative predictive value. Based on multivariable analysis, MA < 60 was an independent predictor of DIC (odds ratio 5.616 (95% confidence interval: 3.213–9.818)). (4) Conclusions: In patients with septic shock, the MA value in TEG could be a valuable tool for early prediction of DIC.
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18
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Boscolo A, Spiezia L, De Cassai A, Pasin L, Pesenti E, Zatta M, Zampirollo S, Andreatta G, Sella N, Pettenuzzo T, Rose K, Simioni P, Navalesi P. Are thromboelastometric and thromboelastographic parameters associated with mortality in septic patients? A systematic review and meta-analysis. J Crit Care 2020; 61:5-13. [PMID: 33049490 DOI: 10.1016/j.jcrc.2020.09.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/21/2020] [Accepted: 09/30/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Thromboelastometry/elastography (ROTEM/TEG) showed promising results for diagnosis of sepsis-induced coagulopathy, but their association with the outcome is unclear. Our aim was to assess any difference in ROTEM/TEG measurements between septic survivors and non-survivors. METHODS Pubmed, Web of Science, Embase and Cochrane Library databases were investigated. The research aimed to include any randomized or observational study: i) on septic adult patients admitted to Intensive Care Unit (ICU) or Emergency Department (ED); ii) including ROTEM/TEG; iii) assessing mortality. RESULTS Seven prospective and four retrospective observational studies (952 patients) were included. According to the INTEM/kaolin-assay, clotting time (CT)/R (standardized mean difference(SMD) -0.29, 95% CI -0.49 to -0.09, p = 0.004) and clot formation time (CFT)/K (SMD -0.42, 95% CI -0.78 to -0.06, p = 0.02) were shorter in survivors. According to the EXTEM-assay, CT was shorter (MD -11.66 s, 95% CI -22.59 to -0.73, p = 0.04), while MCF was higher (MD 3.49 mm, 95% CI 0.43 to 6.55, p = 0.03) in survivors. A hypocoagulable profile was more frequent in non-survivors (OR 0.31, 95%CI 0.18 to 0.55, p < 0.0001). Overall, the risk of bias of the included studies was moderate and the quality of evidence low. CONCLUSIONS Hypocoagulability and lower MCF in EXTEM may be associated with higher mortality in sepsis.
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Affiliation(s)
- Annalisa Boscolo
- Anaesthesia and Intensive Care Unit, Padua University Hospital, Italy.
| | - Luca Spiezia
- Department of Medicine, Thrombotic and Haemorrhagic Diseases Unit, University of Padua, Italy
| | | | - Laura Pasin
- Anaesthesia and Intensive Care Unit, Padua University Hospital, Italy
| | - Elisa Pesenti
- Department of Medicine-DIMED, University of Padua, Italy
| | - Matteo Zatta
- Department of Medicine-DIMED, University of Padua, Italy
| | | | | | - Nicolò Sella
- Department of Medicine-DIMED, University of Padua, Italy
| | | | - Kirstin Rose
- Department of Obstetrics and Gynaecology, Royal Alexandria Hospital, Paisley, Scotland, United Kingdom
| | - Paolo Simioni
- Department of Medicine, Thrombotic and Haemorrhagic Diseases Unit, University of Padua, Italy
| | - Paolo Navalesi
- Anaesthesia and Intensive Care Unit, Padua University Hospital, Italy; Department of Medicine-DIMED, University of Padua, Italy
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19
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Tyler PD, Yang LM, Snider SB, Lerner AB, Aird WC, Shapiro NI. New Uses for Thromboelastography and Other Forms of Viscoelastic Monitoring in the Emergency Department: A Narrative Review. Ann Emerg Med 2020; 77:357-366. [PMID: 32988649 DOI: 10.1016/j.annemergmed.2020.07.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
Patients frequently visit the emergency department with conditions that place them at risk of worse outcomes when accompanied by coagulopathy. Routine tests of coagulation-prothrombin time, partial thromboplastin time, platelets, and fibrinogen-have shortcomings that limit their use in providing emergency care. One alternative is to investigate coagulation disturbance with viscoelastic monitoring (VEM), a coagulation test that measures the timing and strength of blood clot development in real time. VEM is widely used and studied in cardiac surgery, liver transplant surgery, anesthesia, and trauma. In this article, we review the technique of VEM and the biologic rationale of using it in addition to routine tests of coagulation in emergency clinical situations. Then, we review the evidence (or lack thereof) for using VEM in the diagnosis and treatment of specific conditions. Finally, we describe the limitations of the test and future directions for clinical use and research in emergency medicine.
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Affiliation(s)
- Patrick D Tyler
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Lauren M Yang
- Department of Medicine, Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Samuel B Snider
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Adam B Lerner
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - William C Aird
- Department of Medicine, Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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20
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Satre Buisson L. Coagulopathie associée au COVID-19 : les éléments essentiels pour l’anesthésiste-réanimateur. LE PRATICIEN EN ANESTHESIE REANIMATION 2020; 24:190-195. [PMID: 32837214 PMCID: PMC7357462 DOI: 10.1016/j.pratan.2020.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Coagulation disorders are commonly reported in patients suffering from COVID-19 pneumonia. These are associated to an increase incidence of thrombotic disorders associated with an increase mortality rate. D-Dimers concentrations > 3 μg/L, fibrinogen > 8 g/L and decreased platelets count are associated with an increased thrombotic risk. These biological markers have to be closely monitored during ICU stay. The diagnosis of pulmonary embolism could be difficult in this setting. However, it has to be evoked in case of worsening hypoxemia unexplained by other reason and/or right ventricular failure. The thrombotic risk can be scored to adapt the thromboprophylactic treatment, impaired renal function and overweight making it even more difficult.
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Affiliation(s)
- Léa Satre Buisson
- Service d’anesthésie-réanimation, hôpital Saint-Antoine, DMU DREAM, hôpitaux Sorbonne université, Assistance publique–Hôpitaux de Paris, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
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21
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Yuriditsky E, Horowitz JM, Merchan C, Ahuja T, Brosnahan SB, McVoy L, Berger JS. Thromboelastography Profiles of Critically Ill Patients With Coronavirus Disease 2019. Crit Care Med 2020; 48:1319-1326. [PMID: 32618696 PMCID: PMC7314320 DOI: 10.1097/ccm.0000000000004471] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The rate of thromboembolic events among patients with coronavirus disease 2019 is high; however, there is no robust method to identify those at greatest risk. We reviewed thromboelastography studies in critically ill patients with coronavirus disease 2019 to characterize their coagulation states. DESIGN Retrospective. SETTING Tertiary ICU in New York City. PATIENTS Sixty-four patients with coronavirus disease 2019 admitted to the ICU with thromboelastography performed. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Fifty percent of patients had a clotting index in the hypercoagulable range (clotting index > 3) (median 3.05). Reaction time and K values were below the lower limit of normal in 43.8% of the population consistent with a hypercoagulable profile. The median α angle and maximum amplitude (75.8° and 72.8 mm, respectively) were in the hypercoagulable range. The α angle was above reference range in 70.3% of patients indicative of rapid clot formation. Maximum amplitude, a factor of fibrinogen and platelet count and function, and a measure of clot strength was above reference range in 60.1% of patients. Thirty-one percent had thromboembolic events; thromboelastography parameters did not correlate with events in our cohort. Those with D-dimer values greater than 2,000 were more likely to have shorter reaction times compared with those with D-dimer levels less than or equal to 2,000 (4.8 vs 5.6 min; p = 0.001). CONCLUSIONS A large proportion of critically ill patients with coronavirus disease 2019 have hypercoagulable thromboelastography profiles with additional derangements related to fibrinogen and platelet function. As the majority of patients have an elevated thromboelastography maximum amplitude, a follow-up study evaluating platelet aggregation would be instructive.
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Affiliation(s)
- Eugene Yuriditsky
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
| | - James M Horowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
| | | | - Tania Ahuja
- Department of Pharmacy, NYU Langone Health, New York, NY
| | - Shari B Brosnahan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Langone Health, New York, NY
| | - Lauren McVoy
- Department of Pathology, NYU Langone Health, New York, NY
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
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22
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Patel BV, Arachchillage DJ, Ridge CA, Bianchi P, Doyle JF, Garfield B, Ledot S, Morgan C, Passariello M, Price S, Singh S, Thakuria L, Trenfield S, Trimlett R, Weaver C, Wort SJ, Xu T, Padley SPG, Devaraj A. Pulmonary Angiopathy in Severe COVID-19: Physiologic, Imaging, and Hematologic Observations. Am J Respir Crit Care Med 2020; 202:690-699. [PMID: 32667207 PMCID: PMC7462405 DOI: 10.1164/rccm.202004-1412oc] [Citation(s) in RCA: 211] [Impact Index Per Article: 52.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023] Open
Abstract
Rationale: Clinical and epidemiologic data in coronavirus disease (COVID-19) have accrued rapidly since the outbreak, but few address the underlying pathophysiology.Objectives: To ascertain the physiologic, hematologic, and imaging basis of lung injury in severe COVID-19 pneumonia.Methods: Clinical, physiologic, and laboratory data were collated. Radiologic (computed tomography (CT) pulmonary angiography [n = 39] and dual-energy CT [DECT, n = 20]) studies were evaluated: observers quantified CT patterns (including the extent of abnormal lung and the presence and extent of dilated peripheral vessels) and perfusion defects on DECT. Coagulation status was assessed using thromboelastography.Measurements and Results: In 39 consecutive patients (male:female, 32:7; mean age, 53 ± 10 yr [range, 29-79 yr]; Black and minority ethnic, n = 25 [64%]), there was a significant vascular perfusion abnormality and increased physiologic dead space (dynamic compliance, 33.7 ± 14.7 ml/cm H2O; Murray lung injury score, 3.14 ± 0.53; mean ventilatory ratios, 2.6 ± 0.8) with evidence of hypercoagulability and fibrinolytic "shutdown". The mean CT extent (±SD) of normally aerated lung, ground-glass opacification, and dense parenchymal opacification were 23.5 ± 16.7%, 36.3 ± 24.7%, and 42.7 ± 27.1%, respectively. Dilated peripheral vessels were present in 21/33 (63.6%) patients with at least two assessable lobes (including 10/21 [47.6%] with no evidence of acute pulmonary emboli). Perfusion defects on DECT (assessable in 18/20 [90%]) were present in all patients (wedge-shaped, n = 3; mottled, n = 9; mixed pattern, n = 6).Conclusions: Physiologic, hematologic, and imaging data show not only the presence of a hypercoagulable phenotype in severe COVID-19 pneumonia but also markedly impaired pulmonary perfusion likely caused by pulmonary angiopathy and thrombosis.
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Affiliation(s)
- Brijesh V. Patel
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer
- Centre for Haematology, Department of Immunology and Inflammation, and
| | - Deepa J. Arachchillage
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Adult Intensive Care
| | | | | | | | | | | | | | | | - Susanna Price
- Department of Haematology
- Department of Adult Intensive Care, and
| | - Suveer Singh
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer
- Department of Adult Intensive Care, and
| | | | | | | | | | - S. John Wort
- Department of Haematology
- The Pulmonary Hypertension Service, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Tina Xu
- Department of Adult Intensive Care, and
| | | | | | - the Severe Acute Respiratory Failure Service and The Departments of Anaesthesia and Critical Care, Royal Brompton Hospital
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer
- Centre for Haematology, Department of Immunology and Inflammation, and
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Adult Intensive Care
- Department of Haematology
- Department of Radiology
- Department of Adult Intensive Care, and
- The Pulmonary Hypertension Service, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
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Luo LL, Mei H, Hu Y. [Progress in quantitative diagnosis of sepsis-induced disseminated intravascular coagulation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:433-436. [PMID: 32536146 PMCID: PMC7342063 DOI: 10.3760/cma.j.issn.0253-2727.2020.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- L L Luo
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - H Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Y Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Yoon S, Lim J, Park CM, Lee DS, Park JB, Choi K, Yoo K, Gil E, Yoon KW. Thromboelastographic Evaluation in Patients with Severe Sepsis or Septic Shock: A Preliminary Analysis. JOURNAL OF ACUTE CARE SURGERY 2020. [DOI: 10.17479/jacs.2020.10.2.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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25
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Su Y, Hou JY, Ma GG, Hao GW, Luo JC, Yu SJ, Liu K, Zheng JL, Xue Y, Luo Z, Tu GW. Comparison of the proximal and distal approaches for axillary vein catheterization under ultrasound guidance (PANDA) in cardiac surgery patients susceptible to bleeding: a randomized controlled trial. Ann Intensive Care 2020; 10:90. [PMID: 32643012 PMCID: PMC7343682 DOI: 10.1186/s13613-020-00703-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 06/26/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The present study aimed at comparing the success rate and safety of proximal versus distal approach for ultrasound (US)-guided axillary vein catheterization (AVC) in cardiac surgery patients susceptible to bleeding. METHODS In this single-center randomized controlled trial, cardiac surgery patients susceptible to bleeding and requiring AVC were randomized to either the proximal or distal approach group for US-guided AVC. Patients susceptible to bleeding were defined as those who received oral antiplatelet drugs or anticoagulants for at least 3 days. Success rate, catheterization time, number of attempts, and mechanical complications within 24 h were recorded for each procedure. RESULTS A total of 198 patients underwent randomization: 99 patients each to the proximal and distal groups. The proximal group had the higher first puncture success rate (75.8% vs. 51.5%, p < 0.001) and site success rate (93.9% vs. 83.8%, p = 0.04) than the distal group. However, the overall success rates between the two groups were similar (99.0% vs. 99.0%; p = 1.00). Moreover, the proximal group had fewer average number of attempts (p < 0.01), less access time (p < 0.001), and less successful cannulation time (p < 0.001). There was no significant difference in complications between the two groups, such as major bleeding, minor bleeding, arterial puncture, pneumothorax, nerve injuries, and catheter misplacements. CONCLUSIONS For cardiac surgery patients susceptible to bleeding, both proximal and distal approaches for US-guided AVC can be considered as feasible and safe methods of central venous cannulation. In terms of the first puncture success rate and cannulation time, the proximal approach is superior to the distal approach. Trial registration Clinicaltrials.gov, NCT03395691. Registered January 10, 2018, https://clinicaltrials.gov/ct2/show/NCT03395691?cond=NCT03395691&draw=1&rank=1 .
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Affiliation(s)
- Ying Su
- grid.8547.e0000 0001 0125 2443Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032 China
| | - Jun-yi Hou
- grid.8547.e0000 0001 0125 2443Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032 China
| | - Guo-guang Ma
- grid.8547.e0000 0001 0125 2443Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032 China
| | - Guang-wei Hao
- grid.8547.e0000 0001 0125 2443Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032 China
| | - Jing-chao Luo
- grid.8547.e0000 0001 0125 2443Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032 China
| | - Shen-ji Yu
- grid.8547.e0000 0001 0125 2443Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032 China
| | - Kai Liu
- grid.8547.e0000 0001 0125 2443Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032 China
| | - Ji-li Zheng
- grid.413087.90000 0004 1755 3939Department of Nursing, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032 China
| | - Yan Xue
- grid.413087.90000 0004 1755 3939Department of Nursing, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032 China
| | - Zhe Luo
- grid.8547.e0000 0001 0125 2443Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032 China
- grid.8547.e0000 0001 0125 2443Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, No. 668 Jinghu Road, Huli District, Xiamen, 361015 China
| | - Guo-wei Tu
- grid.8547.e0000 0001 0125 2443Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032 China
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Thromboelastography and rotational thromboelastometry for the surgical intensivist: A narrative review. J Trauma Acute Care Surg 2020; 86:710-721. [PMID: 30633093 DOI: 10.1097/ta.0000000000002206] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Viscoelastic tests (VETs), specifically thromboelastography (TEG) and rotational thromboelastometry (ROTEM), are gaining popularity in the management of critically ill surgical patients with hemorrhage or thrombosis due to their comprehensive characterization of the coagulation process and point-of-care availability in comparison to conventional coagulation tests (CCTs). We review current evidence for VET use in patients in the surgical intensive care unit (SICU). METHODS We searched PUBMED, EMBASE and the Cochrane Library through May 30, 2018 for articles that evaluated the use of VETs in patient populations and clinical scenarios germane to the surgical intensivist. Individual articles were critically evaluated for relevance and appropriate methodology using a structured technique. Information on patient characteristics, timing and methods of CCTs/VETs, and outcomes was collected and summarized in narrative form. RESULTS Of 2,589 identified articles, 36 were included. Five (14%) were interventional studies and 31 (86%) were observational. Twenty-five (69%) evaluated TEG, 11 (31%) ROTEM and 18 (50%) CCTs. Investigated outcomes included quantitative blood loss (13 (36%)), blood product transfusion (9 (25%)), thromboembolic events (9 (25%)) and mortality (6 (17%)). We identified 12 clinical scenarios with sufficient available evidence, much of which was of limited quantity and poor methodological quality. Nonetheless, research supports the use of VETs for guiding early blood product administration in severe traumatic hemorrhage and for the prediction of abstract excess bleeding following routine cardiac surgery. In contrast, evidence suggests VET-based heparin dosing strategies for venous thromboembolism prophylaxis are not superior to standard dosing in SICU patients. CONCLUSION While VETs have the potential to impact the care of critically ill surgical patients in many ways, current evidence for their use is limited, mainly because of poor methodological quality of most available studies. Further high-quality research, including several ongoing randomized controlled trials, is needed to elucidate the role of TEG/ROTEM in the SICU population. LEVEL OF EVIDENCE Systematic review, level IV.
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Luo C, Zhuang B, Chen Z. Thromboelastography Parameters as Predictors for Long-Term Survival in Critically Ill Patients. Clin Appl Thromb Hemost 2020; 25:1076029619876028. [PMID: 31549520 PMCID: PMC6829951 DOI: 10.1177/1076029619876028] [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
Thromboelastography (TEG) is used for monitoring abnormal blood coagulation in critically
ill patients. However, the correlation between TEG parameters and long-term survival in
these patients is unknown. We aimed to quantify the effect of TEG on long-term survival of
critically ill patients. Critically ill patients undergoing TEG were retrospectively
examined. Baseline patient characteristics and coagulation function indexes were compared.
Cox regression, receiver–operating characteristic curve analysis, and Kaplan-Meier
survival estimate curve were performed. We included 167 critically ill patients. Clot
formation speed (K) and reaction time (R) were higher, whereas maximum amplitude (MA) and
angle were lower in the mortality group than in the survival group (P
< .01). All TEG parameters were risk factors for 2-year survival in critically ill
patients (P < .01). The area under the curve of MA for predicting
2-year survival was 0.756 (95% confidence interval: 0.670-0.841). The Kaplan-Meier
survival estimate curve analysis showed that MA predicted 2-year survival of critically
ill patients(P < .01). Maximum amplitude can effectively predict
2-year survival of critically ill patients, indicating the influence of the coagulation
system on these patients.
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Affiliation(s)
- Cuizhu Luo
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Department of Critical Care Medicine, JiangXi PingXiang People's Hospital, PingXiang, JiangXi, China
| | - Bingjie Zhuang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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Abstract
OBJECTIVES Critically ill patients with deranged conventional coagulation tests are often perceived to have an increased bleeding risk. Whether anticoagulant prophylaxis for these patients should be withheld is contentious. This study assessed the ability of using in vitro clot strength, as measured by thromboelastography, to predict thromboembolism in patients with abnormal coagulation profiles. DESIGN Prospective cohort study. SETTING A tertiary ICU. PATIENTS Two-hundred and fifteen critically ill coagulopathic patients with thrombocytopenia and/or a derangement in at least one conventional coagulation test (international normalized ratio or activated partial thromboplastin time) within 48 hours of ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thromboelastography was performed for all study patients, and plasma thrombotic biomarkers were measured in a nested cohort (n = 40). Of the 215 patients included, 34 patients (16%) developed subsequent thromboembolism-predominantly among those with a normal (maximum amplitude, 54-72 mm) or increased (maximum amplitude, > 72 mm) in vitro clot strength on thromboelastography (91%; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.64-0.83). The ability of the maximum amplitude to predict thromboembolism was comparable to plasma P-selectin concentrations (thromboembolism, 78.3 ng/mL vs no thromboembolism, 59.5 ng/mL; p = 0.031; area under the receiver-operating characteristic curve, 0.73; 95% CI, 0.52-0.95). In addition, patients with an increased maximum amplitude were also less likely to receive blood product transfusions within 24 hours of testing compared with those with a subnormal maximum amplitude (12.8% vs 69.2%, respectively; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.67-0.80). CONCLUSIONS In patients with abnormal coagulation profiles, an increased in vitro clot strength on thromboelastography was associated with an increased risk of thromboembolism, and a reduced risk of requiring transfusion compared with those with a normal or reduced in vitro clot strength.
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Boscolo A, Spiezia L, Campello E, Consolaro EM, Ori C, Simioni P. The prognostic role of ThromboDynamic Index in patients with severe sepsis. Intern Emerg Med 2020; 15:163-168. [PMID: 31267438 DOI: 10.1007/s11739-019-02137-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 06/25/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Annalisa Boscolo
- UOC Anaesthesia and Intensive Care Unit, Department of Medicine-DIMED, Padova University Hospital, Padua, Italy
| | - Luca Spiezia
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine-DIMED, Padova University Hospital, 105, Via Ospedale Civile, 35100, Padua, Italy
| | - Elena Campello
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine-DIMED, Padova University Hospital, 105, Via Ospedale Civile, 35100, Padua, Italy
| | - Elisabetta Maria Consolaro
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine-DIMED, Padova University Hospital, 105, Via Ospedale Civile, 35100, Padua, Italy
| | - Carlo Ori
- UOC Anaesthesia and Intensive Care Unit, Department of Medicine-DIMED, Padova University Hospital, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine-DIMED, Padova University Hospital, 105, Via Ospedale Civile, 35100, Padua, Italy.
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30
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Prediction of bleeding by thromboelastography in ICU patients with haematological malignancy and severe sepsis. Blood Coagul Fibrinolysis 2019; 29:683-688. [PMID: 30439767 DOI: 10.1097/mbc.0000000000000777] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
: ICU patients with haematological malignancy have an increased risk of bleeding. Recently, global haemostatic methods such as thromboelastography (TEG) have gained impact in evaluating coagulation. The aim of this study was to observe whether TEG could predict bleeding in haematological ICU patients with severe sepsis. Post-hoc single-centre analysis of patients with haematological malignancy included in the Scandinavian Starch for Severe Sepsis/Septic Shock (6S) trial. Clinical characteristics, TEG measurements and details regarding bleeding complications were retrieved from the 6S database. The association between TEG and bleeding were analysed by Cox regression and receiver operating characteristic curves. A total of 202 patients with severe sepsis were admitted to the ICU of Rigshospitalet, Copenhagen and included in the 6S trial. Forty-one had haematological malignancy and were analysed in the current study. During ICU stay, 20 patients (49%) had bleeding complications and 13 (32%) patients bled within the first 5 ICU days. We observed no associations between TEG and subsequent bleeding in Cox regression models. TEG variables at baseline had low predictive value for bleeding. Baseline TEG variables did not add value in identifying patients with high risk of bleeding in ICU patients with haematological malignancy and severe sepsis.
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Zhou W, Zhou W, Bai J, Ma S, Liu Q, Ma X. TEG in the monitoring of coagulation changes in patients with sepsis and the clinical significance. Exp Ther Med 2019; 17:3373-3382. [PMID: 30988714 PMCID: PMC6447775 DOI: 10.3892/etm.2019.7342] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 01/22/2019] [Indexed: 12/11/2022] Open
Abstract
Application values of thromboelastography (TEG) in dynamic monitoring of coagulation parameters of sepsis patients were investigated. Eighty-one patients with sepsis who were admitted to the ICU department of the General Hospital of Ningxia Medical University from April 1, 2015 to December 31, 2015 were collected. Clinical data of the patients were collected. Data were compared using 5 grouping methods: i) the 81 patients were divided into the sepsis group (n=45) and sepsis shock group (n=36); ii) patients were divided into two groups: group A (APACHE II score ≤13, n=51); group B (APACHE II score >13, n=30); iii) according to Disseminated Intravascular Coagulation Diagnosis Integral System (CDSS), patients were divided into non-disseminated intravascular coagulation (DIC) group (CDSS <7 points) and DIC group (CDSS ≥7 points); TEG indexes were compared between the two groups; iv) correlation between TEG indexes and Sequential Organ Failure Assessment (SOFA) scores was analyzed; v) patients were divided into survival group and non-survival group and correlations between TEG indicators and prognosis were analyzed. At 6 h after ICU entry, compared with sepsis group, R value and K time were significantly increased, LY30 was also increased, while MA value, coagulation index (CI), and α angle were significantly decreased in the septic shock group (P<0.05). At 6 h after ICU entry, compared with sepsis group, R value and K time were significantly increased, while MA value, CI, and α angle were significantly decreased in the septic shock group (P<0.05). Compared with the non-DIC group, the DIC group had prolonged K time, decreased α angle, increased R value, and decreased CI and MA value (P<0.05). With increase of SOFA scores, R value and K value increased significantly, and α angle, MA value, and CI decreased significantly (P<0.05). According to TEG, platelet function and fibrinogen function of DIC patients were significantly reduced, and the body showed hypocoagulability.
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Affiliation(s)
- Wenyan Zhou
- Department of Intensive Care Unit, General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Wenjie Zhou
- Department of Intensive Care Unit, General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Jijia Bai
- Department of Intensive Care Unit, General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Shenmao Ma
- Resident Standardized Training Base, General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Qinfu Liu
- Department of Intensive Care Unit, General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
| | - Xigang Ma
- Department of Intensive Care Unit, General Hospital of Ningxia Medical University, Yinchuan, Ningxia 750004, P.R. China
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Saini A, Spinella PC, Ignell SP, Lin JC. Thromboelastography Variables, Immune Markers, and Endothelial Factors Associated With Shock and NPMODS in Children With Severe Sepsis. Front Pediatr 2019; 7:422. [PMID: 31681719 PMCID: PMC6814084 DOI: 10.3389/fped.2019.00422] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/03/2019] [Indexed: 01/17/2023] Open
Abstract
Objective: Evaluate hemostatic dysfunction in pediatric severe sepsis by thromboelastography (TEG) and determine if TEG parameters are associated with new or progressive multiple organ dysfunction syndrome (NPMODS) or shock, defined as a lactate ≥2mmol/L. We explored the relationship between TEG variables, selective cytokines, and endothelial factors. Design: Prospective observational. Setting: Single-center, quaternary care pediatric intensive care unit. Patients: Children aged 6- months to 14- years with severe sepsis with expected PICU stay for >72 h. Interventions: None. Measurements and Main Results: Twenty-eight children were enrolled with median (IQR) age of 7.3 years (4.4-11.4), PELOD score (study day-1) of 11(1.25-13), and PICU length of stay of 10 days (5-28). TEG-defined hypercoagulable state occurred most commonly in 73% (94/129) of samples, followed by hypocoagulable state in 7.8% (10/129) and mixed coagulation state in 1.5% (2/129) of samples in the study cohort. In contrast, hypocoagulable state occurred most commonly in 66% (98/148) of samples based on standard coagulation parameters. In the seven children who developed shock with NPMODS compared to eight patients with shock without NPMODS and 12 patients with severe sepsis only, we found more profound coagulopathy [thrombocytopenia (p = 0.04), elevated INR (p = 0.038), low fibrinogen level (p = 0.049), and low TEG-G value (p = 0.01)] and higher peak of interleukin-6 (p = 0.0014) and IL-10 (p = 0.007). Peak lactate in the first 5 study days had moderate correlation with standard coagulation assays, TEG parameters, and selective cytokines. Peak lactate did not correlate with markers of endothelial activation. Lowest TEG -G value had moderate correlation with peak IL-10 (ρ -0.442, p =0.019), peak VCAM (ρ - 0.495, p = 0.007), and peak lactate (ρ -0.542, p = 0.004) in the first 5 study days. A combination of TEG-G value and IL-6 concentration best discriminated children with shock and NPMODS [AUC 0.979 (95%CI 0.929-1.00), p < 0.001]. Conclusion: This exploratory analysis of hemostasis dysfunction on TEG in pediatric severe sepsis suggests that while hypercoagulability is more common, a hypocoagulable state is associated with shock and NPMODS. In addition, TEG abnormalities are also associated with immune and endothelial factors. A larger cohort study is needed to validate these findings.
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Affiliation(s)
- Arun Saini
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Steven P Ignell
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
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Hawkins RB, Raymond SL, Hartjes T, Efron PA, Larson SD, Andreoni KA, Thomas EM. Review: The Perioperative Use of Thromboelastography for Liver Transplant Patients. Transplant Proc 2018; 50:3552-3558. [PMID: 30577236 DOI: 10.1016/j.transproceed.2018.07.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/09/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022]
Abstract
Thromboelastography (TEG) is a viscoelastic test that allows rapid evaluation of clot formation and fibrinolysis from a sample of whole blood. TEG is increasingly utilized to guide blood product resuscitation in surgical patients and transfusions for liver transplant patients. Patients with severe liver failure have significant derangement of their clotting function due to impaired production of procoagulant and anticoagulant factors. Traditional coagulation studies are limited by the short time needed for the result and provide little information about the dynamics and strength of clot formation. In addition, traditional coagulation studies do not correlate well with bleeding episodes and may lead to over-transfusion of various blood products. Evidence is less robust regarding the use of TEG for transfusion management decisions in severe liver failure patients awaiting, undergoing, or immediately after liver transplant surgery. However, the available evidence suggests that systematic implementation of TEG rather than traditional coagulation studies results in the administration of fewer blood products without increased mortality or complications. The purpose of this study is to review the literature regarding the use of TEG in liver failure patients prior to liver transplant, intraoperatively, and postoperatively. Additional high-quality randomized controlled studies should be performed to evaluate the use of TEG to guide transfusion decisions, particularly in the postoperative period following liver transplantation.
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Affiliation(s)
- R B Hawkins
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - S L Raymond
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - T Hartjes
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA; University of Florida College of Nursing, Gainesville, FL, USA
| | - P A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - S D Larson
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - K A Andreoni
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - E M Thomas
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
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Russell L, Holst LB, Lange T, Liang X, Ostrowski SR, Perner A. Effects of anemia and blood transfusion on clot formation and platelet function in patients with septic shock: a substudy of the randomized TRISS trial. Transfusion 2018; 58:2807-2818. [DOI: 10.1111/trf.14904] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 06/17/2018] [Accepted: 07/23/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Lene Russell
- Department of Intensive Care; Copenhagen University Hospital-Rigshospitalet; Copenhagen Denmark
- Copenhagen Academy for Medical Education and Simulation-Rigshospitalet; Copenhagen Denmark
| | - Lars Broksø Holst
- Department of Intensive Care; Copenhagen University Hospital-Rigshospitalet; Copenhagen Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health; University of Copenhagen; Copenhagen Denmark
- Centre for Statistical Science; Peking University; Beijing China
| | - Xuan Liang
- Department of Econometrics and Business Statistics; Monash University; Victoria Australia
| | - Sisse Rye Ostrowski
- Department of Clinical Immunology, Capital Region Blood Bank; Copenhagen University Hospital; Copenhagen Rigshospitalet Denmark
| | - Anders Perner
- Department of Intensive Care; Copenhagen University Hospital-Rigshospitalet; Copenhagen Denmark
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The Role of Thromboelastography Testing in the Emergency Medicine, Trauma Center, and Critical Care Environments. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2018. [DOI: 10.1007/s40138-018-0151-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Russell L, Madsen MB, Dahl M, Kampmann P, Perner A. Prediction of bleeding and thrombosis by standard biochemical coagulation variables in haematological intensive care patients. Acta Anaesthesiol Scand 2018; 62:196-206. [PMID: 29124749 DOI: 10.1111/aas.13036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 10/10/2017] [Accepted: 10/20/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE We assessed the value of standard biochemical coagulation parameters in predicting bleeding, thrombosis and mortality in adult Intensive Care Unit (ICU) patients with haematological malignancies. METHODS We screened all patients with acute leukaemia and myelodysplastic syndrome admitted to a university hospital ICU during 2008-2012. Data were obtained from the clinical chemistry laboratory database and patient files. We graded bleeding according to the World Health Organisation (WHO)-system within 24-h, within 5-days and during the whole ICU stay. We analysed the predictive values of laboratory parameters using multiple logistic regression and receiver operator characteristics (ROC) curves. As we previously have established that platelet count at admission was associated with bleeding, we focused on International Normalised Ratio (INR), activated pro-thrombin time (APTT), anti-thrombin, D-dimer and fibrinogen, and markers of infection (C-reactive protein, pro-calcitonin), kidney function (creatinine) and tissue damage (lactate dehydrogenase (LDH)). RESULTS We included 116 patients; 66 (57%) had at least one bleeding episode and 11 (9%) patients had at least one thrombotic event. The differences in coagulation values when bleeding compared to baseline values were minor. INR was the only variable we found associated with subsequent bleeding within 24 h from admission to ICU (odds ratio 2.91, 95% CI: 1.01-8.43, P = 0.048). ROC analyses did not show predictive value of any of the other variables with regards to bleeding and none of the variables were associated with thrombosis in adjusted analyses. Increased levels of LDH at admission were associated with increased 7-day and 30-day mortality. CONCLUSIONS Increased INR at admission was associated with a higher rate of bleeding in ICU patients with haematological malignancies. No other biochemical coagulation or other parameter had any association with bleeding, thrombosis or mortality except increased LDH, which at ICU admission was associated with increased 30-day mortality.
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Affiliation(s)
- L. Russell
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
- Copenhagen Academy for Medical Education and Simulation; University of Copenhagen and The Capital Region of Denmark; Copenhagen Denmark
| | - M. B. Madsen
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - M. Dahl
- Department of Clinical Biochemistry; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
- Department of Clinical Biochemistry; Zealand University Hospital; Køge Denmark
| | - P. Kampmann
- Department of Haematology; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - A. Perner
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
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Russell L, Holst LB, Kjeldsen L, Stensballe J, Perner A. Risks of bleeding and thrombosis in intensive care unit patients with haematological malignancies. Ann Intensive Care 2017; 7:119. [PMID: 29230562 PMCID: PMC5725397 DOI: 10.1186/s13613-017-0341-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 11/28/2017] [Indexed: 02/14/2023] Open
Abstract
Background Patients with malignant haematological disease and especially those who require intensive care have an increased risk of bleeding and thrombosis, but none of these data were obtained in ICU patients only. We assessed the incidence of bleeding and thrombotic complications, use of blood products and risk factors for bleeding in an adult population of ICU patients with haematological malignancies. Methods We screened all patients with acute leukaemia and myelodysplastic syndrome admitted to a university hospital ICU during 2008–2012. Bleeding in ICU was scored according to the WHO grading system, and risk factors were evaluated using unadjusted and adjusted analyses. Results In total, 116 of 129 ICU patients were included; their median length of stay was 7 (IQR 2–16) days. Of these, 66 patients (57%) had at least one bleeding episode in ICU; they bled for 3 (2–6) days and most often from lower and upper airways and upper GI tract. Thirty-nine (59%) of the 66 patients had severe or debilitating (WHO grade 3 or 4) bleeding. The median platelet count on the day of grade 3 or 4 bleeding was 23 × 109 per litre (IQR 13–39). Nine patients (8%) died in ICU following a bleeding episode; five of these had intra-cerebral haemorrhage. Platelet count on admission was associated with subsequent bleeding (adjusted odds ratio 1.18 (95% CI 1.03–1.35) for every 10 × 109 per litre drop in platelet count, p = 0.016). Eleven of the 116 patients (9%) developed a clinically significant thrombosis in ICU, which was the cause of death in four patients. The median platelet count was 20 × 109 per litre (15–48) at the time of thrombosis. The patients received a median of 6 units of red blood cells, 1 unit of fresh frozen plasma and 8 units of platelet concentrates in ICU. Conclusions Severe and debilitating bleeding complications were frequent in our ICU patients with haematological malignancies, but thrombosis also occurred in spite of low platelet counts. Platelet count on ICU admission was associated with subsequent bleeding. Electronic supplementary material The online version of this article (10.1186/s13613-017-0341-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lene Russell
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,Copenhagen Academy for Medical Education and Simulation, University of Copenhagen and The Capital Region of Denmark, Copenhagen, Denmark.
| | - Lars Broksø Holst
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Lars Kjeldsen
- Department of Haematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
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38
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ICM focus on thrombosis and bleeding. Intensive Care Med 2017; 43:1910-1911. [PMID: 29063131 DOI: 10.1007/s00134-017-4966-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/11/2017] [Indexed: 12/17/2022]
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Perner A, Holst LB, Haase N, Hjortrup PB, Møller MH. Common Sense Approach to Managing Sepsis. Crit Care Clin 2017; 34:127-138. [PMID: 29149934 DOI: 10.1016/j.ccc.2017.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Sepsis results in many deaths, prolonged suffering among survivors and relatives, and high use of resources both in developed and developing countries. The updated Surviving Sepsis Campaign guidelines should aid clinicians in improving the identification and management of these patients, but many uncertainties remain because most of the guidance is based on low-quality evidence. This article discusses how to use some of the specific items of the guidelines together with a common-sense approach to aid clinical management of patients with sepsis while trying to balance the potential benefit and harm of the items.
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Affiliation(s)
- Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark.
| | - Lars B Holst
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Nicolai Haase
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Peter B Hjortrup
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
| | - Morten H Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen DK-2100, Denmark
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40
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Benediktsson S, Frigyesi A, Kander T. Routine coagulation tests on ICU admission are associated with mortality in sepsis: an observational study. Acta Anaesthesiol Scand 2017; 61:790-796. [PMID: 28681428 DOI: 10.1111/aas.12918] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 05/02/2017] [Accepted: 05/15/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low platelet count on admission to an intensive care unit (ICU) is associated with increased mortality and is thus included in some severity scoring systems such as the simplified acute physiologic score 3 (SAPS 3); however it is unclear whether other routine coagulation tests also predict mortality. The purpose of this retrospective single-centre study was to investigate whether activated partial thromboplastin time (APTT) or prothrombin time - international normalized ratio (PT-INR) measured on admission to the ICU in patients with severe sepsis or septic shock may be associated with mortality independent of SAPS 3 score. METHODS All patients admitted to a tertiary general ICU from 2007 to 2014 diagnosed with severe sepsis or septic shock were eligible. Results from APTT and PT-INR within 1.5 h of admission as well as SAPS 3 were used as independent variables in a Cox regression. RESULTS Of total 5485 ICU admissions during the study period we identified 647 unique patients with severe sepsis or septic shock. APTT and PT-INR were found to correlate significantly with mortality with a hazard ratio (HR) of 1.014 [95% confidence interval of HR (1.006-1.023)] for APTT and 1.422 (1.117-1.811) for PT-INR. HR for SAPS 3 was 1.036 (1.028-1.044). CONCLUSION Activated partial thromboplastin time prolongation and raised PT-INR on ICU admission in patients with severe sepsis or septic shock is associated with increased mortality independent of SAPS 3 score. This indicates that APTT prolongation and PT-INR increase represents morbidity that is not accounted for in SAPS 3.
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Affiliation(s)
- S. Benediktsson
- Department of Intensive and Perioperative Care; Skåne University Hospital; Lund Sweden
- Department of Clinical Sciences; Section for Anaesthesiology and Intensive Care; Lund University; Lund Sweden
| | - A. Frigyesi
- Department of Intensive and Perioperative Care; Skåne University Hospital; Lund Sweden
- Department of Clinical Sciences; Section for Anaesthesiology and Intensive Care; Lund University; Lund Sweden
| | - T. Kander
- Department of Intensive and Perioperative Care; Skåne University Hospital; Lund Sweden
- Department of Clinical Sciences; Section for Anaesthesiology and Intensive Care; Lund University; Lund Sweden
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Müller MCA, Stanworth SJ, Coppens M, Juffermans NP. Recognition and Management of Hemostatic Disorders in Critically Ill Patients Needing to Undergo an Invasive Procedure. Transfus Med Rev 2017. [PMID: 28647217 DOI: 10.1016/j.tmrv.2017.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Abnormal laboratory coagulation test results are frequently documented in critically ill patients, and these patients often also need to undergo invasive procedures. Clinicians have an understandable desire to minimize any perceived heightened risk of bleeding complications in those patients who require invasive procedures. In this setting, prophylactic administration of platelets or plasma is commonplace. This review explores the nature of these sequential statements and the degree to which these statements are supported by evidence. We discuss the complexity of managing the low risk of procedure-related bleeding in a setting where coagulation tests fail to reliably predict this risk. The role of prophylactic transfusion of platelets and plasma and correction of medication-induced coagulopathy is also reviewed. New strategies are required to improve the evidence base, including novel methodological approaches or the use of a clinical scoring system.
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Affiliation(s)
- Marcella C A Müller
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands.
| | - Simon J Stanworth
- Department of Haematology, NHS Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | - Michiel Coppens
- Department of Internal Medicine, Academic Medical Center, Amsterdam, the Netherlands.
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, the Netherlands.
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Early Detection of Disseminated Intravascular Coagulation During Septic Shock: A Multicenter Prospective Study. Crit Care Med 2017; 44:e930-9. [PMID: 27322364 DOI: 10.1097/ccm.0000000000001836] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Inadequate stratification of septic shock patients may result in inappropriate treatment allocation in randomized clinical trials, especially regarding anticoagulant. We previously reported that endothelial-derived microparticles are relevant biomarkers of sepsis-induced disseminated intravascular coagulation. In this validation cohort, we assess microparticles as surrogates of cell activation to improve early disseminated intravascular coagulation diagnosis and patient stratification. DESIGN Prospective observational study in septic shock patients. SETTINGS Four medical ICUs in university hospitals. PATIENTS AND METHODS Two hundred sixty-five patients with septic shock from four ICUs were consecutively enrolled. Disseminated intravascular coagulation was diagnosed according to Japanese Association for Acute Medicine 2006 score. Endothelial- and leukocyte-derived circulating procoagulant microparticles were isolated and quantified by prothrombinase assay at admission, day 3, and day 7. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Two hundred fifty-nine patients were analyzed. Sixty-one had disseminated intravascular coagulation at admission, and 32 developed disseminated intravascular coagulation during the first 24 hours after admission. Multiple logistic regression model confirmed that endothelial cell-derived microparticles were associated with disseminated intravascular coagulation: CD105-microparticles (odds ratio, 2.13) and CD31-microparticles (odds ratio, 0.65) (p < 0.05). Furthermore, CD11a-microparticles to leukocyte ratio evidenced leukocyte activation (odds ratio, 1.59; p < 0.05). Prediction of disseminated intravascular coagulation was also analyzed after exclusion of patients with disseminated intravascular coagulation at admission. A new multiple logistic regression analysis demonstrated the association of CD105-microparticles (> 0.60 nM eq. PhtdSer; odds ratio, 1.67; p < 0.01), platelets count (≤ 127 g/L; odds ratio, 0.99; p < 0.01), and prothrombin time (≤ 58%; odds ratio, 0.98; p < 0.05) with disseminated intravascular coagulation. A combining score at admission is predictive of the absence of disseminated intravascular coagulation (area under the curve, 72.9%; specificity, 71.2%; sensitivity, 71.0%, with a negative predictive value of 93.1% and a positive predictive value of 31.0%). CONCLUSIONS Procoagulant microparticles from endothelial cells and leukocytes reflect a vascular injury during sepsis-induced disseminated intravascular coagulation that precedes obvious activation of coagulation. A combination of prothrombin time, endothelium-derived CD105-microparticles, and platelet count at admission could predict the absence of disseminated intravascular coagulation and allow a better stratification in future randomized clinical trials.
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43
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Benvenuti M, An T, Amaro E, Lovejoy S, Mencio G, Martus J, Mignemi M, Schoenecker JG. Double-Edged Sword: Musculoskeletal Infection Provoked Acute Phase Response in Children. Orthop Clin North Am 2017; 48:181-197. [PMID: 28336041 DOI: 10.1016/j.ocl.2016.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The acute phase response has a crucial role in mounting the body's response to tissue injury. Excessive activation of the acute phase response is responsible for many complications that occur in orthopedic patients. Given that infection may be considered continuous tissue injury that persistently activates the acute phase response, children with musculoskeletal infections are at markedly increased risk for serious complications. Future strategies that modulate the acute phase response have the potential to improve treatment and prevent complications associated with musculoskeletal infection.
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Affiliation(s)
| | - Thomas An
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Emilie Amaro
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Steven Lovejoy
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory Mencio
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey Martus
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Megan Mignemi
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan G Schoenecker
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA; Departments of Orthopaedics, Pharmacology, and Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.
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44
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Coagulation abnormalities identified by thromboelastometry in patients with severe sepsis. Blood Coagul Fibrinolysis 2017; 28:163-170. [DOI: 10.1097/mbc.0000000000000572] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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45
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Toh CH, Alhamdi Y, Abrams ST. Current Pathological and Laboratory Considerations in the Diagnosis of Disseminated Intravascular Coagulation. Ann Lab Med 2017; 36:505-12. [PMID: 27578502 PMCID: PMC5011102 DOI: 10.3343/alm.2016.36.6.505] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/21/2016] [Accepted: 07/22/2016] [Indexed: 01/06/2023] Open
Abstract
Systemically sustained thrombin generation in vivo is the hallmark of disseminated intravascular coagulation (DIC). Typically, this is in response to a progressing disease state that is associated with significant cellular injury. The etiology could be infectious or noninfectious, with the main pathophysiological mechanisms involving cross-activation among coagulation, innate immunity, and inflammatory responses. This leads to consumption of both pro- and anticoagulant factors as well as endothelial dysfunction and disrupted homeostasis at the blood vessel wall interface. In addition to the release of tissue plasminogen activator (tPA) and soluble thrombomodulin (sTM) following cellular activation and damage, respectively, there is the release of damage-associated molecular patterns (DAMPs) such as extracellular histones and cell-free DNA. Extracellular histones are increasingly recognized as significantly pathogenic in critical illnesses through direct cell toxicity, the promotion of thrombin generation, and the induction of neutrophil extracellular trap (NET) formation. Clinically, high circulating levels of histones and histone–DNA complexes are associated with multiorgan failure, DIC, and adverse patient outcomes. Their measurements as well as that of other DAMPs and molecular markers of thrombin generation are not yet applicable in the routine diagnostic laboratory. To provide a practical diagnostic tool for acute DIC, a composite scoring system using rapidly available coagulation tests is recommended by the International Society on Thrombosis and Haemostasis. Its usefulness and limitations are discussed alongside the advances and unanswered questions in DIC pathogenesis.
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Affiliation(s)
- Cheng Hock Toh
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom.,Roald Dahl Haemostasis & Thrombosis Centre, Royal Liverpool University Hospital, Liverpool, United Kingdom.
| | - Yasir Alhamdi
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Simon T Abrams
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
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Muzaffar SN, Baronia AK, Azim A, Verma A, Gurjar M, Poddar B, Singh RK. Thromboelastography for Evaluation of Coagulopathy in Nonbleeding Patients with Sepsis at Intensive Care Unit Admission. Indian J Crit Care Med 2017; 21:268-273. [PMID: 28584429 PMCID: PMC5455019 DOI: 10.4103/ijccm.ijccm_72_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Thromboelastography (TEG) is a global test of coagulation which analyzes the whole coagulation process. TEG is popular in trauma, liver transplant, and cardiac surgeries, but studies in sepsis are limited. We have assessed the utility of TEG for evaluating coagulopathy in nonbleeding patients with sepsis. Materials and Methods: A prospective, observational study was done in 12-bedded Intensive Care Unit (ICU) of a tertiary care hospital in North India, during May 2014-November 2014. After ethical clearance, all patients at ICU admission with sepsis were included in the study. Exclusion criteria were age <18 years, plasma/platelet transfusion before admission, patients on oral antiplatelets/anticoagulants, or with underlying hematological disorders. At admission, blood samples for TEG were analyzed by kaolin-based TEG analyzer within an hour of collecting 2.7 ml citrated blood from arterial line. TEG parameters included reaction time (R), K time (K), alpha angle (a), maximum amplitude (MA), coagulation index (CI), and lysis index (LY 30). Results: In TEG, mean values of R, K, a, MA, CI, and LY30 were 6.45 ± 2.59 (min), 1.67 ± 0.96 (min), 66.37 ± 10.44 (0), 67.08 ± 10.33 (mm), 0.63 ± 3.46, and 2.23 ± 4.08 (%), respectively. In conventional coagulation assay (CCA), mean values of international normalized ratio (INR), platelet, and fibrinogen were 1.63 ± 0.57, 153.96 ± 99.16 (×103 /mm3), and 301.33 ± 112.82 (mg/dl), respectively. In those with deranged INR (INR ≥1.6), 60% were normocoagulable and 20% were hypercoagulable. Similarly, 81% patients with thrombocytopenia (platelet count <1,00,000/mL) were normocoagulable. Conclusion: TEG could differentiate among normocoagulant, hypocoagulant, hypercoagulant states (unlike CCAs). Patients with septic shock had trend toward hypocoagulant state while those without shock had trend toward hypercoagulant state.
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Affiliation(s)
- Syed Nabeel Muzaffar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arvind Kumar Baronia
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Afzal Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anupam Verma
- Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Banani Poddar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ratender Kumar Singh
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Strandberg G, Lipcsey M, Eriksson M, Lubenow N, Larsson A. Analysis of thromboelastography, PT, APTT and fibrinogen in intraosseous and venous samples-an experimental study. Scand J Trauma Resusc Emerg Med 2016; 24:131. [PMID: 27809922 PMCID: PMC5094096 DOI: 10.1186/s13049-016-0318-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 10/06/2016] [Indexed: 12/31/2022] Open
Abstract
Background Laboratory analysis of coagulation is often important in emergencies. If vascular access is challenging, intraosseous catheterization may be necessary for treatment. We studied the analysis of coagulation parameters in intraosseous aspirate during stable conditions and after major haemorrhage in a porcine model. Methods Ten anesthetized pigs received central venous and intraosseous catheters and samples were taken for analysis of thromboelastography (TEG), prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen concentration. Analyses were repeated after removal of 50 % of the calculated blood volume and resuscitation with crystalloid. Intraosseous and venous values were compared. Results Bleeding and resuscitation resulted in haemodilution and hypotension. Median TEG reaction time was shorter in intraosseous than in venous samples before (1.6 vs 4.6 min) and after (1.6 vs 4.7 min) haemodilution. Median maximal amplitude was smaller in intraosseous samples at baseline (68.3 vs 76.4 mm). No major differences were demonstrated for the other TEG parameters. The intraosseous samples often coagulated in vitro, making analysis of PT, APTT and fibrinogen difficult. After haemodilution, TEG maximal amplitude and α-angle, and fibrinogen concentration, were decreased and PT increased. Discussion The intraosseous samples were clinically hypercoagulable and the TEG demonstrated a shortened reaction time. The reason for this may hypothetically be found in the composition of the IO aspirate or in the sampling technique. After 50 % haemorrhage and haemodilution, a clinically relevant decrease in fibrinogen concentration and a lower TEG maximal amplitude were observed. Conclusions Although the sample is small, these data indicate that intraosseous samples are hypercoagulable, which may limit their usefulness for coagulation studies. Major haemodilution only moderately affected the studied parameters. Electronic supplementary material The online version of this article (doi:10.1186/s13049-016-0318-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gunnar Strandberg
- Anaesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden. .,Department of Surgical Sciences, Uppsala University, Uppsala University Hospital, 751 85, Uppsala, Sweden.
| | - Miklós Lipcsey
- Hedenstierna laboratory, Anaesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Mats Eriksson
- Anaesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Norbert Lubenow
- Immunology and Transfusion medicine, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Anders Larsson
- Clinical Chemistry, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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48
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High Levels of Methylarginines Were Associated With Increased Mortality in Patients With Severe Sepsis. Shock 2016; 46:365-72. [DOI: 10.1097/shk.0000000000000649] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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49
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Prevalence of “Flat-Line” Thromboelastography During Extracorporeal Membrane Oxygenation for Respiratory Failure in Adults. ASAIO J 2016; 62:302-9. [DOI: 10.1097/mat.0000000000000325] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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50
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Assessment of Haemostasis in Disseminated Intravascular Coagulation by Use of Point-of-Care Assays and Routine Coagulation Tests, in Critically Ill Patients; A Prospective Observational Study. PLoS One 2016; 11:e0151202. [PMID: 26959974 PMCID: PMC4784845 DOI: 10.1371/journal.pone.0151202] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 02/23/2016] [Indexed: 01/06/2023] Open
Abstract
Background Disseminated intravascular coagulopathy (DIC) relates to the consumption of coagulation factors and platelets with bleeding and micro thrombosis events. Aim The aim of this study was to compare haemostasis parameters in critically ill patients with DIC versus patients without DIC, and in survivors versus non-survivors over time. Correlations between the DIC-score, the degree of organ failure and the haemostasis were assessed. Method Patients admitted to the intensive care unit with a condition known to be associated with DIC and with an expected length of stay of >3 days were included. Routine laboratory tests, prothrombin time, activated partial thromboplastin time, platelet count, fibrinogen concentration and D-dimer were measured. Coagulation and platelet function were assessed with two point-of-care devices; Multiplate and ROTEM. DIC scores were calculated according to the International Society on Thrombosis and Haemostasis and Japanese Association for Acute Medicine. Results Blood was sampled on days 0–1, 2–3 and 4–10 from 136 patients with mixed diagnoses during 290 sampling events. The point-of-care assays indicated a hypocoagulative response (decreased platelet aggregation and reduced clot strength) in patients with DIC and, over time, in non-survivors compared to survivors. Patients with DIC as well as non-survivors had decreased fibrinolysis as shown by ROTEM. DIC scores were higher in non-survivors than in survivors. Conclusions Patients with DIC displayed signs of a hypocoagulative response and impaired fibrinolysis, which was also evident over time in non-survivors. Patients with DIC had a higher mortality rate than non-DIC patients, and DIC scores were higher in non-survivors than in survivors.
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