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Moore HB, Barrett CD, Moore EE, Pieracci FM, Sauaia A. Differentiating Pathologic from Physiologic Fibrinolysis: Not as Simple as Conventional Thrombelastography. J Am Coll Surg 2024; 239:30-41. [PMID: 38299576 DOI: 10.1097/xcs.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Conventional rapid thrombelastography (rTEG) cannot differentiate fibrinolysis shutdown from hypofibrinolysis, as both of these patient populations have low fibrinolytic activity. Tissue plasminogen activator (tPA) TEG can identify depletion of fibrinolytic inhibitors, and its use in combination with rTEG has the potential to differentiate all 3 pathologic fibrinolytic phenotypes after trauma. We hypothesize tPA-TEG and rTEG in combination can further stratify fibrinolysis phenotypes postinjury to better stratify risk for mortality. STUDY DESIGN Adult trauma patients (981) with both rTEG and tPA-TEG performed less than 2 hours postinjury were included. rTEG lysis at 30 minutes after maximum amplitude (LY30) was used to initially define fibrinolysis phenotypes (hyperfibrinolysis >3%, physiologic 0.9% to 3%, and shutdown <0.9%), with Youden Index then used to define pathologic extremes of tPA-TEG LY30 (tPA sensitive [depletion of fibrinolytic inhibitors] vs resistant) resulting in 9 groups that were assessed for risk of death. RESULTS The median New Injury Severity Score was 22, 21% were female, 45% had penetrating injury, and overall mortality was 13%. The tPA-TEG LY30 inflection point for increased mortality was >35.5% (tPA sensitive, odds ratio mortality 9.2, p < 0.001) and <0.3% (tPA resistance, odds ratio mortality 6.3, p = 0.04). Of the 9 potential fibrinolytic phenotypes, 5 were associated with increased mortality. Overall, the 9 phenotypes provided a significantly better prediction of mortality than rTEG or tPA-TEG alone (areas under the operating characteristics curves = 0.80 vs 0.63 and 0.75, respectively, p < 0.0001). These could be condensed to 3 pathologic phenotypes (true hyperfibrinolysis, early fibrinolysis shutdown, and hypofibrinolysis). CONCLUSIONS The combination of rTEG and tPA-TEG increases the ability to predict mortality and suggests patient-specific strategies for improved outcomes.
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Affiliation(s)
- Hunter B Moore
- From the Department of Surgery, Transplant Institution, AdventHealth at Porter Hospital, Denver, CO (HB Moore)
| | - Christopher D Barrett
- Department of Surgery, University of Nebraska School of Medicine, Omaha, NE (Barrett)
| | - Ernest E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO (EE Moore, Pieracci)
| | - Fredric M Pieracci
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO (EE Moore, Pieracci)
| | - Angela Sauaia
- Department of Public Health, University of Colorado School of Public Health, Aurora, CO (Sauaia)
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2
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Haberkorn CJ, Severance CC, Wetmore NC, West WG, Ng PC, Cendali F, Pitotti C, Schauer SG, Maddry JK, Bebarta VS, Hendry-Hofer TB. Intramuscular administration of tranexamic acid in a large swine model of hemorrhage with hyperfibrinolysis. J Trauma Acute Care Surg 2024; 96:735-741. [PMID: 37962201 DOI: 10.1097/ta.0000000000004207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Traumatic injury with subsequent hemorrhage is one of the leading causes of mortality among military personnel and civilians alike. Posttraumatic hemorrhage accounts for 40% to 50% of deaths in severe trauma patients occurring secondary to direct vessel injury or the development of trauma-induced coagulopathy (TIC). Hyperfibrinolysis plays a major role in TIC and its presence increases a patient's risk of mortality. Early therapeutic intervention with intravenous (IV) tranexamic acid (TXA) prevents development of hyperfibrinolysis and subsequent TIC leading to decreased mortality. However, obtaining IV access in an austere environment can be challenging. In this study, we evaluated the efficacy of intramuscular (IM) versus IV TXA at preventing hyperfibrinolysis in a hemorrhaged swine. METHODS Yorkshire cross swine were randomized on the day of study to receive IM or IV TXA or no treatment. Swine were sedated, intubated, and determined to be hemodynamically stable before experimentation. Controlled hemorrhaged was induced by the removal of 30% total blood volume. After hemorrhage, swine were treated with 1,000 mg of IM or IV TXA. Control animals received no treatment. Thirty minutes post-TXA treatment, fibrinolysis was induced with a 50-mg bolus of tissue plasminogen activator. Blood samples were collected to evaluate blood TXA concentrations, blood gases, blood chemistry, and fibrinolysis. RESULTS Blood TXA concentrations were significantly different between administration routes at the early time points but were equivalent by 20 minutes after injection, remaining consistently elevated for up to 3 hours postadministration. Induction of fibrinolysis resulted in 87.18 ± 4.63% lysis in control animals, compared with swine treated with IM TXA, 1.96 ± 2.66% and 1.5 ± 0.42% lysis in the IV TXA group. CONCLUSION In the large swine model of hemorrhage with hyperfibrinolysis, IM TXA is bioequivalent and equally efficacious in preventing hyperfibrinolysis as IV TXA administration.
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Affiliation(s)
- Christopher J Haberkorn
- From the Department of Emergency Medicine (C.J.H.), University of Colorado Anschutz Medical Campus; Department of Critical Care (C.J.H.), Children's Hospital Colorado; Department of Emergency Medicine (C.C.S., N.C.W., W.G.W., C.P., V.S.B., T.B.H.-H.), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Emergency Medicine (P.C.N.), Brooke Army Medical Center, Ft Sam Houston, San Antonio, Texas; Department of Biochemistry and Molecular Biology (F.C.), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Department of Emergency Medicine (S.G.S.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; Departments of Anesthesiology (S.G.S.) and Emergency Medicine (S.G.S.), University of Colorado Anschutz Medical Campus, Aurora, Colorado; Uniformed Services University of the Health Sciences (J.K.M.), Bethesda, Maryland; and Brooke Army Medical Center (J.K.M.), JBSA, Fort Sam Houston, Texas
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3
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Skaugen JT, Yazer MH, Sprogøe U. Impact of systematic variations in hematocrit and platelet count on thrombelastometry tissue factor activated assay parameters. Transfusion 2024; 64 Suppl 2:S185-S190. [PMID: 38587089 DOI: 10.1111/trf.17809] [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: 12/29/2023] [Revised: 03/02/2024] [Accepted: 03/10/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Thromboelastogram testing is increasingly being used to manage patients with massive bleeding. An earlier study found that the test results were influenced by the hematocrit (Hct) and platelet (PLT) concentrations. This study sought to determine if these factors confounded the results of a different manufacturer's thromboelastography testing. METHODS Using freshly collected whole blood from volunteers and stored red blood cells (RBC) and plasma, the whole blood was manipulated to achieve different Hct values and PLT concentrations. Each reconstituted whole blood sample was tested in triplicate on the ROTEM Delta device and the ExTEM results were recorded. RESULTS Many of the ExTEM results varied according to the Hct and PLT concentration. In particular, the ExTEM clot formation time (CFT) was abnormally long when the Hct was 45% and the PLT concentration was ≤75 × 109/L, normalizing only when the PLT count was ≥100 × 109/L. CFT samples with Hct 25% and 35% were also abnormal with low PLT concentrations but normalized at lower PLT concentrations compared to the Hct 45% samples. The ExTEM angle also demonstrated abnormal results when the Hct was 45% and the PLT concentration was ≤50 × 109/L. The ExTEM A10 and maximum clot firmness (MCF) tests tended to also be abnormal when the Hct was between 25% and 45% and the platelet concentrations were below 75 × 109/L. CONCLUSION While thromboelastogram testing is gaining popularity for managing bleeding patients, clinicians should be aware of these confounding factors when making transfusion decisions based on their results.
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Affiliation(s)
- Julie T Skaugen
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- University of Southern Denmark, Odense, Denmark
| | - Ulrik Sprogøe
- Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
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Donohue JK, Iyanna N, Lorence JM, Brown JB, Guyette FX, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Sperry JL. Missingness matters: a secondary analysis of thromboelastography measurements from a recent prehospital randomized tranexamic acid clinical trial. Trauma Surg Acute Care Open 2024; 9:e001346. [PMID: 38375027 PMCID: PMC10875568 DOI: 10.1136/tsaco-2023-001346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
Background Tranexamic acid (TXA) has been hypothesized to mitigate coagulopathy in patients after traumatic injury. Despite previous prehospital clinical trials demonstrating a TXA survival benefit, none have demonstrated correlated changes in thromboelastography (TEG) parameters. We sought to analyze if missing TEG data contributed to this paucity of findings. Methods We performed a secondary analysis of the Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport Trial. We compared patients that received TEG (YES-TEG) and patients unable to be sampled (NO-TEG) to analyze subgroups in which to investigate TEG differences. TEG parameter differences across TXA intervention arms were assessed within subgroups disproportionately present in the NO-TEG relative to the YES-TEG cohort. Generalized linear models controlling for potential confounders were applied to findings with p<0.10 on univariate analysis. Results NO-TEG patients had lower prehospital systolic blood pressure (SBP) (100 (78, 140) vs 125 (88, 147), p<0.01), lower prehospital Glascow Coma Score (14 (3, 15) vs 15 (12, 15), p<0.01), greater rates of prehospital intubation (39.4% vs 24.4%, p<0.01) and greater mortality at 30 days (36.4% vs 6.8%, p<0.01). NO-TEG patients had a greater international normalized ratio relative to the YES-TEG subgroup (1.2 (1.1, 1.5) vs 1.1 (1.0, 1.2), p=0.04). Within a severe prehospital shock cohort (SBP<70), TXA was associated with a significant decrease in clot lysis at 30 min on multivariate analysis (β=-27.6, 95% CI (-51.3 to -3.9), p=0.02). Conclusions Missing data, due to the logistical challenges of sampling certain severely injured patients, may be associated with a lack of TEG parameter changes on TXA administration in the primary analysis. Previous demonstration of TXA's survival benefit in patients with severe prehospital shock in tandem with the current findings supports the notion that TXA acts at least partially by improving clot integrity. Level of evidence Level II.
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Affiliation(s)
- Jack K Donohue
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nidhi Iyanna
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John M Lorence
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Frances X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | | | - Terence O'Keeffe
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Matthew D Neal
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Zipperle J, Schmitt FCF, Schöchl H. Point-of-care, goal-directed management of bleeding in trauma patients. Curr Opin Crit Care 2023; 29:702-712. [PMID: 37861185 DOI: 10.1097/mcc.0000000000001107] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to consider the clinical value of point-of-care (POC) testing in coagulopathic trauma patients with traumatic brain injury (TBI) and trauma-induced coagulopathy (TIC). RECENT FINDINGS Patients suffering from severe TBI or TIC are at risk of developing pronounced haemostatic disorders. Standard coagulation tests (SCTs) are insufficient to reflect the complexity of these coagulopathies. Recent evidence has shown that viscoelastic tests (VETs) identify haemostatic disorders more rapidly and in more detail than SCTs. Moreover, VET results can guide coagulation therapy, allowing individualised treatment, which decreases transfusion requirements. However, the impact of VET on mortality remains uncertain. In contrast to VETs, the clinical impact of POC platelet function testing is still unproven. SUMMARY POC SCTs are not able to characterise the complexity of trauma-associated coagulopathy. VETs provide a rapid estimation of underlying haemostatic disorders, thereby providing guidance for haemostatic therapy, which impacts allogenic blood transfusion requirements. The value of POC platelet function testing to identify platelet dysfunction and guide platelet transfusion is still uncertain.
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Affiliation(s)
- Johannes Zipperle
- Ludwig Boltzmann Institute for Traumatology, the Research Centre in Cooperation with AUVA, Vienna
| | - Felix C F Schmitt
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, the Research Centre in Cooperation with AUVA, Vienna
- Paracelsus Medical University, Salzburg, Austria
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Gomez Builes JC, Baker AJ, Callum J, Barahi S, Bai J, Karkouti K, Nisenbaum R, Sholzberg M. Evaluation of the association of factor XIII at hospital arrival and outcomes in a cohort of severely injured patients. J Thromb Haemost 2023; 21:3085-3098. [PMID: 37453456 DOI: 10.1016/j.jtha.2023.07.002] [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: 03/05/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Severe traumatic bleeding depletes coagulation factor XIII (FXIII) and fibrinogen. However, the role of FXIII level in bleeding-related outcomes is unknown. OBJECTIVES To evaluate the association between FXIII levels at hospital arrival and critical administration threshold (≥3 red blood cell units in 1 hour within the first 24 hours), bleeding-related outcomes, death, and baseline characteristics. METHODS A retrospective cohort study was conducted in severely injured adult patients (Injury Severity Score of ≥22 or ≥2 red blood cell units transfused in 24 hours) admitted to a level 1 trauma center. Clinical and laboratory data were collected. Baseline FXIII antigen levels were measured in banked patient plasma. Multivariable logistic and linear regression models were used to estimate the association between FXIII levels, outcomes, and baseline characteristics. RESULTS Three hundred sixty-four of 1730 subjects admitted during a 2-year period were analyzed. Median age was 44 years (IQR, 27-62 years), and median Injury Severity Score was 29 (IQR, 22-34). FXIII levels were not associated with critical administration threshold (odds ratio [OR], 1.06; 95% CI, 0.97-1.17) or death (OR, 0.98; 95% CI, 0.90-1.07). FXIII was associated with major bleeding (OR, 1.10; 95% CI, 1.02-1.2) and massive transfusion (OR, 1.25; 95% CI, 1.08-1.44). Lower baseline FXIII levels were associated with arrival from a referring hospital (FXIII level, -0.07 U/mL; 95% CI, -0.11 to -0.03), hemoglobin (FXIII level, -0.05 U/mL; 95% CI, -0.07 to -0.03), fibrinogen level (FXIII level, -0.05 U/mL; 95% CI, -0.08 to -0.02), and platelet count (FXIII level, -0.02 U/mL; 95% CI, -0.04 to -0.008). CONCLUSIONS Baseline FXIII levels in severely injured patients were inconsistently associated with bleeding-related outcomes and mortality. However, their association with major bleeding warrants further investigation of the role of FXIII in massively transfused patients with trauma.
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Affiliation(s)
- Johana Carolina Gomez Builes
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada. https://twitter.com/cgomezbuiles
| | - Andrew J Baker
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada; Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sunti Barahi
- Department of Anesthesia and Pain Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Johnny Bai
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Management, University Health Network, Sinai Health System, and Women's College Hospital, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; MAP Centre for Urban Health Solutions, Toronto, Ontario, Canada; Applied Health Research Centre, Toronto, Ontario, Canada; Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Department of Hematology, St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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7
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Perka C, von Heymann C, Lier H, Kaufner L, Treskatsch S. Die perioperative Gabe von Tranexamsäure. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023; 161:532-537. [PMID: 37336245 DOI: 10.1055/a-2055-8178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The application of tranexamic acid (TXA) during endoprosthetic surgical procedures has significantly increased in recent years. Due its ability to reduce perioperative blood loss and avert the need for blood transfusions as well as wound drainage, TXA is becoming part of a 'standard practice'. However, TXA is currently not approved for the application during endoprosthetic procedures and therefore, a benefit-risk analysis should always be conducted. Prophylactic administration of TXA without prior patient consent is only justified if fibrinolytic bleeding is expected and there are no contraindications or relevant risk factors for thromboembolic complications. Respectively, no patient consent is required when a therapeutic dose of TXA is administered in the context of fibrinolytic bleeding. The following guidelines provide updated recommendations based on the current state of knowledge on TXA optimal timing, routes of administration and dosing regimen.
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Affiliation(s)
- Carsten Perka
- Klinik für Orthopädie, Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Christian von Heymann
- Klinik für Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Vivantes Klinikum im Friedrichshain, Berlin, Berlin, Deutschland
| | - Heiko Lier
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät und Uniklinik Köln, Köln, Deutschland
| | - Lutz Kaufner
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité ‒ Universitätsmedizin Berlin, Berlin, Deutschland
| | - Sascha Treskatsch
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité ‒ Universitätsmedizin Berlin, Berlin, Deutschland
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Ramanujam V, DiMaria S, Varma V. Thromboelastography in the Perioperative Period: A Literature Review. Cureus 2023; 15:e39407. [PMID: 37362492 PMCID: PMC10287184 DOI: 10.7759/cureus.39407] [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] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not designed for assessment of dynamically changing coagulation conditions during the perioperative time. However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which represent the use of TEG in the perioperative period. The included studies were categorized under various settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust results to standardize its use in different perioperative settings.
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Affiliation(s)
- Vendhan Ramanujam
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Stephen DiMaria
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Vivek Varma
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
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9
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Jones WL, Ramos CR, Banerjee A, Moore EE, Hansen KC, Coleman JR, Kelher M, Neeves KB, Silliman CC, Di Paola J, Branchford BR. Apolipoprotein A-I, elevated in trauma patients, inhibits platelet activation and decreases clot strength. Platelets 2022; 33:1119-1131. [PMID: 35659185 PMCID: PMC9547822 DOI: 10.1080/09537104.2022.2078488] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 04/19/2022] [Accepted: 04/29/2022] [Indexed: 10/18/2022]
Abstract
Apolipoprotein A-I (ApoA-I) is elevated in the plasma of a subgroup of trauma patients with systemic hyperfibrinolysis. We hypothesize that apoA-I inhibits platelet activation and clot formation. The effects of apoA-I on human platelet activation and clot formation were assessed by whole blood thrombelastography (TEG), platelet aggregometry, P-selectin surface expression, microfluidic adhesion, and Akt phosphorylation. Mouse models of carotid artery thrombosis and pulmonary embolism were used to assess the effects of apoA-I in vivo. The ApoA-1 receptor was investigated with transgenic mice knockouts (KO) for the scavenger receptor class B member 1 (SR-BI). Compared to controls, exogenous human apoA-I inhibited arachidonic acid and collagen-mediated human and mouse platelet aggregation, decreased P-selectin surface expression and Akt activation, resulting in diminished clot strength and increased clot lysis by TEG. ApoA-I also decreased platelet aggregate size formed on a collagen surface under flow. In vivo, apoA-I delayed vessel occlusion in an arterial thrombosis model and conferred a survival advantage in a pulmonary embolism model. SR-BI KO mice significantly reduced apoA-I inhibition of platelet aggregation versus wild-type platelets. Exogenous human apoA-I inhibits platelet activation, decreases clot strength and stability, and protects mice from arterial and venous thrombosis via the SR-BI receptor.
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Affiliation(s)
- Wilbert L Jones
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Christopher R. Ramos
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Anirban Banerjee
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Ernest E. Moore
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
- Dept. of Surgery, Denver Health Medical Center, Denver CO
| | - Kirk C. Hansen
- Department of Biochemistry/Molecular Genetics, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Julia R. Coleman
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Marguerite Kelher
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
- Vitalant Research Institute, Denver, CO
| | - Keith B. Neeves
- Department of Pediatrics, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
- Department of Bioengineering, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Christopher C. Silliman
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
- Department of Pediatrics, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
- Vitalant Research Institute, Denver, CO
| | - Jorge Di Paola
- Dept. of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, MO
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10
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Richards JE, Fedeles BT. Coagulation Management in Trauma: Do We Need a Viscoelastic Hemostatic Assay? CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00532-2] [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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11
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Morton AP, Hadley JB, Ghasabyan A, Kelher MR, Moore EE, Bevers S, Dzieciatkowska M, Hansen KC, Cohen MS, Banerjee A, Silliman CC. The α-globin chain of hemoglobin potentiates tissue plasminogen activator induced hyperfibrinolysis in vitro. J Trauma Acute Care Surg 2022; 92:159-166. [PMID: 34538821 PMCID: PMC8692352 DOI: 10.1097/ta.0000000000003410] [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] [Indexed: 01/03/2023]
Abstract
BACKGROUND Severe injury predisposes patients to trauma-induced coagulopathy, which may be subdivided by the state of fibrinolysis. Systemic hyperfibrinolysis (HF) occurs in approximately 25% of these patients with mortality as high as 70%. Severe injury also causes the release of numerous intracellular proteins, which may affect coagulation, one of which is hemoglobin, and hemoglobin substitutes induce HF in vitro. We hypothesize that the α-globin chain of hemoglobin potentiates HF in vitro by augmenting plasmin activity. METHODS Proteomic analysis was completed on a pilot study of 30 injured patients before blood component resuscitation, stratified by their state of fibrinolysis, plus 10 healthy controls. Different concentrations of intact hemoglobin A, the α- and β-globin chains, or normal saline (controls) were added to whole blood, and tissue plasminogen activator (tPA)-challenged thrombelastography was used to assess the degree of fibrinolysis. Interactions with plasminogen (PLG) were evaluated using surface plasmon resonance. Tissue plasminogen activator-induced plasmin activity was evaluated in the presence of the α-globin chain. RESULTS Only the α- and β-globin chains increased in HF patients (p < 0.01). The α-globin chain but not hemoglobin A or the β-globin chain decreased the reaction time and significantly increased lysis time 30 on citrated native thrombelastographies (p < 0.05). The PLG and α-globin chain had interaction kinetics similar to tPA:PLG, and the α-globin chain increased tPA-induced plasmin activity. CONCLUSIONS The α-globin chain caused HF in vitro by binding to PLG and augmenting plasmin activity and may represent a circulating "moonlighting" mediator released by the tissue damage and hemorrhagic shock inherent to severe injury. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Alexander P Morton
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Jamie B Hadley
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
| | - Arsen Ghasabyan
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Marguerite R. Kelher
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Ernest E Moore
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Shaun Bevers
- Department of Biochemistry and Molecular Genetics, School of Medicine University of Colorado Denver, Aurora, CO
| | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, School of Medicine University of Colorado Denver, Aurora, CO
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, School of Medicine University of Colorado Denver, Aurora, CO
| | - Mitchell S Cohen
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
| | - Anirban Banerjee
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
| | - Christopher C Silliman
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Pediatrics, School of Medicine University of Colorado Denver, Aurora, CO
- Vitalant Research Institute, Vitalant Mountain Division, Denver, CO
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12
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Duchesne J, Taghavi S, Ninokawa S, Harris C, Schroll R, McGrew P, McGinness C, Reily R, Guidry C, Tatum D. After 800 Mtp Events, Mortality Due to Hemorrhagic Shock Remains High and Unchanged Despite Several In-Hospital Hemorrhage Control Advancements. Shock 2021; 56:70-78. [PMID: 34048424 DOI: 10.1097/shk.0000000000001817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Numerous advancements in hemorrhage control and volume replacement that comprise damage control resuscitation (DCR) have been implemented in the last decade to reduce deaths from bleeding. We sought to determine the impact of DCR interventions on mortality over 12 years in a massive transfusion protocol (MTP) population. We hypothesized that mortality would be decreased in later years, which would have used more DCR interventions. STUDY DESIGN This was a retrospective review of all MTP patients treated at a large regional Level I trauma center from 2008 to 2019. Interventions by year of implementation examined included MTP 1:1 ratio (2009), liquid plasma (2010), tranexamic acid (2012), prehospital tourniquets (2013), REBOA/TEG (2017), satellite blood station (2018), and whole blood transfusion (2019). Relative risk and odds of mortality for DCR interventions were examined. RESULTS There were 824 MTP patients included. The cohort was primarily male (80.6%) injured by penetrating mechanism (68.1%) with median (interquartile range) age 31 years (23-44) and New Injury Severity Score 25 (16-34). Overall mortality was unchanged [(38.3%-56.6%); P = 0.26]. Tourniquets (P = 0.02) and whole blood (WB) (P = 0.03) were associated with lower unadjusted mortality; only tourniquets remained significant after adjustment (OR: 0.39; 95% CI: 0.17-0.89; P = 0.03). CONCLUSIONS Despite lower mortality with use of tourniquets and WB, mortality rates due to hemorrhage have not improved at our high MTP volume institution, suggesting implementation of new in-hospital strategies is insufficient to reduce mortality. Future efforts should be directed toward moving hemorrhage control and effective resuscitation interventions to the injury scene.
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Affiliation(s)
- Juan Duchesne
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Sharven Taghavi
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Scott Ninokawa
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Charles Harris
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Rebecca Schroll
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Patrick McGrew
- Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Robert Reily
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Chrissy Guidry
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Danielle Tatum
- Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana
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13
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St. John AE, Wang X, Ringgold K, Lim EB, Chien D, Statz ML, Stern SA, White NJ. A Multifunctional, Low-Volume Resuscitation Cocktail Improves Vital Organ Blood Flow and Hemostasis in a Pig Model of Polytrauma with Traumatic Brain Injury. J Clin Med 2021; 10:jcm10235484. [PMID: 34884185 PMCID: PMC8658540 DOI: 10.3390/jcm10235484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/10/2021] [Accepted: 11/16/2021] [Indexed: 12/19/2022] Open
Abstract
The resuscitation of polytrauma with hemorrhagic shock and traumatic brain injury (TBI) is a balance between permissive hypotension and maintaining vital organ perfusion. There is no current optimal solution. This study tested whether a multifunctional resuscitation cocktail supporting hemostasis and perfusion could mitigate blood loss while improving vital organ blood flow during prolonged limited resuscitation. Anesthetized Yorkshire swine were subjected to fluid percussion TBI, femur fracture, catheter hemorrhage, and aortic tear. Fluid resuscitation was started when lactate concentration reached 3–4 mmol/L. Animals were randomized to one of five groups. All groups received hydroxyethyl starch solution and vasopressin. Low- and high-dose fibrinogen (FBG) groups additionally received 100 and 200 mg/kg FBG, respectively. A third group received TXA and low-dose FBG. Two control groups received albumin, with one also including TXA. Animals were monitored for up to 6 h. Blood loss was decreased and vital organ blood flow was improved with low- and high-dose fibrinogen compared to albumin controls, but survival was not improved. There was no additional benefit of high- vs. low-dose FBG on blood loss or survival. TXA alone decreased blood loss but had no effect on survival, and combining TXA with FBG provided no additional benefit. Pooled analysis of all groups containing fibrinogen vs. albumin controls found improved survival, decreased blood loss, and improved vital organ blood flow with fibrinogen delivery. In conclusion, a low-volume resuscitation cocktail consisting of hydroxyethyl starch, vasopressin, and fibrinogen concentrate improved outcomes compare to controls during limited resuscitation of polytrauma.
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14
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Duque P, Calvo A, Lockie C, Schöchl H. Pathophysiology of Trauma-Induced Coagulopathy. Transfus Med Rev 2021; 35:80-86. [PMID: 34610877 DOI: 10.1016/j.tmrv.2021.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
There is no standard definition for trauma-induced coagulopathy (TIC). However, it could be defined as an abnormal hemostatic response secondary to trauma. The terms "early TIC" and "late TIC" have been recently suggested. "Early TIC" would refer to the inability to achieve effective hemostasis exacerbating an uncontrolled bleeding in a shocked patient with ischemia-reperfusion damage (bleeding phenotype) and takes place usually early after injury, whereas "late TIC" would represent a hypercoagulable state after surviving a severe tissue injury, that would contribute to thromboembolic events and multiorgan failure (MOF), (thrombotic phenotype), occurring typically hours after the trauma insult though it could be delayed for days. In addition, severe tissue injury when there is no associated shock could be followed by an early hypercoagulable state, representing an evolutionary maladaptive response of a physiologic mechanism created to increase clot formation and prevent bleeding. Therefore, TIC is not a uniform phenotype, ranging from bleeding to pro-thrombotic profiles. This current concept of TIC is mainly based on the recognition of TIC as a unique clotting disorder following trauma in which alterations in the endothelial function, fibrinolysis regulation and platelet behavior after major trauma are the main cornerstones.
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Affiliation(s)
- Patricia Duque
- Anesthesiology and Critical Care Department, Gregorio Marañon Hospital, Madrid, Spain.
| | - Alberto Calvo
- Anesthesiology and Critical Care Department, Gregorio Marañon Hospital, Madrid, Spain
| | - Christopher Lockie
- Department of Anesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, and Ludwig Boltzmann Institute for experimental and clinical traumatology Vienna, Austria
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, and Ludwig Boltzmann Institute for experimental and clinical traumatology Vienna, Austria
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15
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Vigneshwar NG, Moore HB, Moore EE. Trauma-Induced Coagulopathy: Diagnosis and Management in 2020. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00438-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Keyloun JW, Le TD, Brummel-Ziedins KE, Mclawhorn MM, Bravo MC, Orfeo T, Johnson LS, Moffatt LT, Pusateri AE, Shupp JW. Inhalation Injury is Associated with Endotheliopathy and Abnormal Fibrinolytic Phenotypes in Burn Patients: A Cohort Study. J Burn Care Res 2021; 43:432-439. [PMID: 34089618 PMCID: PMC8946676 DOI: 10.1093/jbcr/irab102] [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: 11/12/2022]
Abstract
Burn injury is associated with endothelial dysfunction and coagulopathy and concomitant inhalation injury increases morbidity and mortality. The aim of this work is to identify associations between inhalation injury (IHI), coagulation homeostasis, vascular endothelium, and clinical outcomes in burn patients. One-hundred and twelve patients presenting to a regional burn center were included in this retrospective cohort study. Whole blood was collected at set intervals from admission through 24 hours and underwent viscoelastic assay with rapid TEG (rTEG). Syndecan-1 (SDC-1) on admission was quantified by ELISA. Patients were grouped by the presence (n=28) or absence (n=84) of concomitant IHI and rTEG parameters, fibrinolytic phenotypes, SDC-1, and clinical outcomes were compared. Of the 112 thermally injured patients, 28 (25%) had IHI. Most patients were male (68.8%) with a median age of 40 (IQR, 29-57) years. Patients with IHI had higher overall mortality (42.68% vs. 8.3%; p<0.0001). rTEG LY30 was lower in patients with IHI at hours 4 and 12 (p<0.05). There was a pattern of increased abnormal fibrinolytic phenotypes among IHI patients. There was a greater proportion of IHI patients with endotheliopathy (SDC-1 > 34 ng/mL) (64.7% vs. 26.4%; p=0.008). There was a pattern of increased mortality among patients with inhalation injury and endotheliopathy (0% vs. 72.7%; p=0.004). Significant differences between patients with and without IHI were found in measures assessing fibrinolytic potential and endotheliopathy. Mortality was associated with abnormal fibrinolysis, endotheliopathy, and inhalation injury. However, the extent to which IHI associated dysfunction is independent of TBSA burn size remains to be elucidated.
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Affiliation(s)
- John W Keyloun
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Tuan D Le
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX.,Department of Epidemiology and Biostatistics, University of Texas Health Science Center, Tyler, TX
| | | | - Melissa M Mclawhorn
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC
| | - Maria C Bravo
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Colchester, VT
| | - Thomas Orfeo
- Department of Biochemistry, Larner College of Medicine, University of Vermont, Colchester, VT
| | - Laura S Johnson
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC.,Department of Biochemistry Georgetown University, Washington, DC
| | | | - Jeffrey W Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC.,Department of Surgery, Georgetown University, Washington, DC.,Department of Biochemistry Georgetown University, Washington, DC
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17
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Wang Y, Xie J, Pei F. Plasma D-dimer and FDP are promising biomarkers to predict perioperative fibrinolysis and bleeding following primary total joint arthroplasty: A STROBE compliant article. Medicine (Baltimore) 2021; 100:e26058. [PMID: 34011123 PMCID: PMC8136990 DOI: 10.1097/md.0000000000026058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/30/2021] [Indexed: 02/05/2023] Open
Abstract
Perioperative bleeding is associated with postoperative hyperfibrinolysis caused by surgical trauma in the setting of total hip and knee arthroplasty (THA/ TKA). The study aimed to clarify the dynamics of postoperative fibrinolytic activity and the values of fibrin degeneration products and thromboelastography (TEG) to guide precisive antifibrinolytic therapy.Forty three patients undergoing primary unilateral THAs and 40 TKAs were included to the prospective observational cohort study. Venous blood sample at different time points (preoperative, intraoperative, postoperative 6 hours, 12 hours, 24 hours, 48 hours) were drawn to test D-dimer, fibrin (-ogen) degradation products (FDP) and TEG.The TEG parameters associated with coagulation (R, K, α, MA, and CI) and fibrinolysis (estimate percent lysis and Ly30) were all in normal range although had a higher level than preoperative time (P < .05). The postoperative levels of D-dimer and FDP were higher than preoperative level (P < .05). The dynamics of D-dimer and FDP presented a bimodal pattern, which peaked at 6 hours postoperatively, then remained and decreased until 24 hours, but would rebound at 48 hours postoperatively with smaller amplitude. Moreover, FDP6h (P = .028), D-Dimer6h (P = .044), FDP12h (P = .009), D-dimer12h (P = .007), and FDP48h (P = .016) were all correlated with total blood loss on POD3.FDP and D-dimer were effective and practical markers for prediction of acute postoperative fibrinolytic activity, which peaked at 6 hours after end of surgery and would maintain for at least 24 hours.
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Affiliation(s)
- Yan Wang
- Core Facility of West China Hospital
| | - Jinwei Xie
- Department of Orthopaedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
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18
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Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, Schöchl H, Hunt BJ, Sauaia A. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021; 7:30. [PMID: 33927200 PMCID: PMC9107773 DOI: 10.1038/s41572-021-00264-3] [Citation(s) in RCA: 298] [Impact Index Per Article: 99.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 12/12/2022]
Abstract
Uncontrolled haemorrhage is a major preventable cause of death in patients with traumatic injury. Trauma-induced coagulopathy (TIC) describes abnormal coagulation processes that are attributable to trauma. In the early hours of TIC development, hypocoagulability is typically present, resulting in bleeding, whereas later TIC is characterized by a hypercoagulable state associated with venous thromboembolism and multiple organ failure. Several pathophysiological mechanisms underlie TIC; tissue injury and shock synergistically provoke endothelial, immune system, platelet and clotting activation, which are accentuated by the 'lethal triad' (coagulopathy, hypothermia and acidosis). Traumatic brain injury also has a distinct role in TIC. Haemostatic abnormalities include fibrinogen depletion, inadequate thrombin generation, impaired platelet function and dysregulated fibrinolysis. Laboratory diagnosis is based on coagulation abnormalities detected by conventional or viscoelastic haemostatic assays; however, it does not always match the clinical condition. Management priorities are stopping blood loss and reversing shock by restoring circulating blood volume, to prevent or reduce the risk of worsening TIC. Various blood products can be used in resuscitation; however, there is no international agreement on the optimal composition of transfusion components. Tranexamic acid is used in pre-hospital settings selectively in the USA and more widely in Europe and other locations. Survivors of TIC experience high rates of morbidity, which affects short-term and long-term quality of life and functional outcome.
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Affiliation(s)
- Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA.
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA.
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Lucy Z Kornblith
- Trauma and Surgical Critical Care, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Matthew D Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Maureane Hoffman
- Duke University School of Medicine, Transfusion Service, Durham VA Medical Center, Durham, NC, USA
| | - Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg and Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | | | - Angela Sauaia
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
- Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
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19
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Pusateri AE, Le TD, Keyloun JW, Moffatt LT, Orfeo T, Brummel-Ziedins KE, McLawhorn MM, Callcut RA, Shupp JW. Early abnormal fibrinolysis and mortality in patients with thermal injury: a prospective cohort study. BJS Open 2021; 5:6248890. [PMID: 33893737 DOI: 10.1093/bjsopen/zrab017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 02/03/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Abnormal fibrinolysis early after injury has been associated with increased mortality in trauma patients, but no studies have addressed patients with burn injury. This prospective cohort study aimed to characterize fibrinolytic phenotypes in burn patients and to see if they were associated with mortality. METHODS Patients presenting to a regional burn centre within 4 h of thermal injury were included. Blood was collected for sequential viscoelastic measurements using thromboelastography (RapidTEG™) over 12 h. The percentage decrease in clot strength 30 min after the time of maximal clot strength (LY30) was used to categorize patients into hypofibrinolytic/fibrinolytic shutdown (SD), physiological (PHYS) and hyperfibrinolytic (HF) phenotypes. Injury characteristics, demographics and outcomes were compared. RESULTS Of 115 included patients, just over two thirds were male. Overall median age was 40 (i.q.r. 28-57) years and median total body surface area (TBSA) burn was 13 (i.q.r. 6-30) per cent. Some 42 (36.5 per cent) patients had severe burns affecting over 20 per cent TBSA. Overall mortality was 18.3 per cent. At admission 60.0 per cent were PHYS, 30.4 per cent were SD and 9.6 per cent HF. HF was associated with increased risk of mortality on admission (odds ratio 12.61 (95 per cent c.i. 1.12 to 142.57); P = 0.041) but not later during the admission when its incidence also decreased. Admission SD was not associated with mortality, but incidence increased and by 4 h and beyond, SD was associated with increased mortality, compared with PHYS (odds ratio 8.27 (95 per cent c.i. 1.16 to 58.95); P = 0.034). DISCUSSION Early abnormal fibrinolytic function is associated with mortality in burn patients.
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Affiliation(s)
- A E Pusateri
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - T D Le
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA.,Department of Epidemiology and Biostatistics, University of Texas Health Science Center, Tyler, Texas, USA
| | - J W Keyloun
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
| | - L T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA.,Department of Biochemistry, Georgetown University, Washington, DC, USA
| | - T Orfeo
- Department of Biochemistry, College of Medicine, University of Vermont, Colchester, Vermont, USA
| | - K E Brummel-Ziedins
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
| | - M M McLawhorn
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA
| | - R A Callcut
- Department of Surgery, University of California Davis School of Medicine, Sacramento, California, USA
| | - J W Shupp
- The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA.,Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC, USA.,Department of Surgery, Georgetown University, Washington, DC, USA
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20
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Thomas KA, Shea SM, Spinella PC. Effects of pathogen reduction technology and storage duration on the ability of cryoprecipitate to rescue induced coagulopathies in vitro. Transfusion 2021; 61:1943-1954. [PMID: 33755208 PMCID: PMC8252673 DOI: 10.1111/trf.16376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/19/2021] [Accepted: 03/09/2021] [Indexed: 12/16/2022]
Abstract
Background Fibrinogen concentrates and cryoprecipitate are currently used for fibrinogen supplementation in bleeding patients with dysfibrinogenemia. Both products provide an abundant source of fibrinogen but take greater than 10 min to prepare for administration. Fibrinogen concentrates lack coagulation factors (i.e., factor VIII [FVIII], factor XIII [FXIII], von Willebrand factor [VWF]) important for robust hemostatic function. Cryoprecipitate products contain these factors but have short shelf lives (<6 h). Pathogen reduction (PR) of cryoprecipitate would provide a shelf‐stable immediately available adjunct containing factors important for rescuing hemostatic dysfunction. Study Design and Methods Hemostatic adjunct study products were psoralen‐treated PR‐cryoprecipitated fibrinogen complex (PR‐Cryo FC), cryoprecipitate (Cryo), and fibrinogen concentrates (FibCon). PR‐Cryo FC and Cryo were stored for 10 days at 20–24°C. Adjuncts were added to coagulopathies (dilutional, 3:7 whole blood [WB]:normal saline; or lytic, WB + 75 ng/ml tissue plasminogen activator), and hemostatic function was assessed by rotational thromboelastometry and thrombin generation. Results PR of cryoprecipitate did not reduce levels of FVIII, FXIII, or VWF. PR‐Cryo FC rescued dilutional coagulopathy similarly to Cryo, while generating significantly more thrombin than FibCon, which also rescued dilutional coagulopathy. Storage out to 10 days at 20–24°C did not diminish the hemostatic function of PR‐Cryo FC. Discussion PR‐Cryo FC provides similar and/or improved hemostatic rescue compared to FibCon in dilutional coagulopathies, and this rescue ability is stable over 10 days of storage. In hemorrhaging patients, where every minute delay is associated with a 5% increase in mortality, the immediate availability of PR‐Cryo FC has the potential to improve outcomes.
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Affiliation(s)
- Kimberly A Thomas
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Susan M Shea
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Philip C Spinella
- Department of Pediatrics, Division of Critical Care, Washington University School of Medicine, St. Louis, Missouri, USA
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21
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Richards JE, Fedeles BT, Chow JH, Morrison JJ, Renner C, Trinh AT, Schlee CS, Koerner K, Grissom TE, Betzold RD, Scalea TM, Kozar RA. Is Tranexamic Acid Associated With Mortality or Multiple Organ Failure Following Severe Injury? Shock 2021; 55:55-60. [PMID: 33337787 DOI: 10.1097/shk.0000000000001608] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) administration is recommended in severely injured trauma patients. We examined TXA administration, admission fibrinolysis phenotypes, and clinical outcomes following traumatic injury and hypothesized that TXA was associated with increased multiple organ failure (MOF). METHODS Two-year, single-center, retrospective investigation. Inclusion criteria were age ≥ 18 years, Injury Severity Score (ISS) >16, admitted from scene of injury, thromboelastography within 30 min of arrival. Fibrinolysis was evaluated by lysis at 30 min (LY30) and fibrinolysis phenotypes were defined as: Shutdown: LY30 ≤ 0.8%, Physiologic: LY30 0.81-2.9%, Hyperfibrinolysis: LY30 ≥ 3.0%. Primary outcomes were 28-day mortality and MOF. The association of TXA with mortality and MOF was assessed among the entire study population and in each of the fibrinolysis phenotypes. RESULTS Four hundred twenty patients: 144/420 Shutdown (34.2%), 96/420 Physiologic (22.9%), and 180/410 Hyperfibrinolysis (42.9%). There was no difference in 28-day mortality by TXA administration among the entire study population (P = 0.52). However, there was a significant increase in MOF in patients who received TXA (11/46, 23.9% vs 16/374, 4.3%; P < 0.001). TXA was associated MOF (OR: 3.2, 95% CI 1.2-8.9), after adjusting for confounding variables. There was no difference in MOF in patients who received TXA in the Physiologic (1/5, 20.0% vs 7/91, 7.7%; P = 0.33) group. There was a significant increase in MOF among patients who received TXA in the Shutdown (3/11, 27.3% vs 5/133, 3.8%; P = 0.001) and Hyperfibrinolysis (7/30, 23.3% vs 5/150, 3.3%; P = 0.001) groups. CONCLUSIONS Administration of TXA following traumatic injury was associated with MOF in the fibrinolysis shutdown and hyperfibrinolysis phenotypes and warrants continued evaluation.
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Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Benjamin T Fedeles
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan H Chow
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan J Morrison
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Corinne Renner
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Anthony T Trinh
- University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Ken Koerner
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Richard D Betzold
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Thomas M Scalea
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Rosemary A Kozar
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
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22
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Kammerer T, Groene P, Sappel SR, Peterss S, Sa PA, Saller T, Giebl A, Scheiermann P, Hagl C, Schäfer ST. Functional Testing for Tranexamic Acid Duration of Action Using Modified Viscoelastometry. Transfus Med Hemother 2020; 48:109-117. [PMID: 33976611 DOI: 10.1159/000511230] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/21/2020] [Indexed: 01/11/2023] Open
Abstract
Introduction Tranexamic acid (TXA) is the standard medication to prevent or treat hyperfibrinolysis. However, prolonged inhibition of lysis (so-called "fibrinolytic shutdown") correlates with increased mortality. A new viscoelastometric test enables bedside quantification of the antifibrinolytic activity of TXA using tissue plasminogen activator (TPA). Materials and Methods Twenty-five cardiac surgery patients were included in this prospective observational study. In vivo, the viscoelastometric TPA test was used to determine lysis time (LT) and maximum lysis (ML) over 96 h after TXA bolus. Additionally, plasma concentrations of TXA and plasminogen activator inhibitor 1 (PAI-1) were measured. Moreover, dose effect curves from the blood of healthy volunteers were performed in vitro. Data are presented as median (25-75th percentile). Results In vivo TXA plasma concentration correlated with LT (r = 0.55; p < 0.0001) and ML (r = 0.62; p < 0.0001) at all time points. Lysis was inhibited up to 96 h (LTTPA-test: baseline: 398 s [229-421 s] vs. at 96 h: 886 s [626-2,175 s]; p = 0.0013). After 24 h, some patients (n = 8) had normalized lysis, but others (n = 17) had strong lysis inhibition (ML <30%; p < 0.001). The high- and low-lysis groups differed regarding kidney function (cystatin C: 1.64 [1.42-2.02] vs. 1.28 [1.01-1.52] mg/L; p = 0.002) in a post hoc analysis. Of note, TXA plasma concentration after 24 h was significantly higher in patients with impaired renal function (9.70 [2.89-13.45] vs.1.41 [1.30-2.34] µg/mL; p < 0.0001). In vitro, TXA concentrations of 10 µg/mL effectively inhibited fibrinolysis in all blood samples. Conclusions Determination of antifibrinolytic activity using the TPA test is feasible, and individual fibrinolytic capacity, e.g., in critically ill patients, can potentially be measured. This is of interest since TXA-induced lysis inhibition varies depending on kidney function.
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Affiliation(s)
- Tobias Kammerer
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Philipp Groene
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Sophia R Sappel
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Paula A Sa
- Department of Anesthesiology, Intensive Care and Emergency, Centro Hospitalar Universitario de Porto, Porto, Portugal
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Giebl
- Department of Transfusion Medicine and Hemostaseology, University Hospital Augsburg, Augsburg, Germany
| | - Patrick Scheiermann
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
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23
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Spinella PC, Thomas KA, Turnbull IR, Fuchs A, Bochicchio K, Schuerer D, Reese S, Coleoglou Centeno AA, Horn CB, Baty J, Shea SM, Meledeo MA, Pusateri AE, Levy JH, Cap AP, Bochicchio GV. The Immunologic Effect of Early Intravenous Two and Four Gram Bolus Dosing of Tranexamic Acid Compared to Placebo in Patients With Severe Traumatic Bleeding (TAMPITI): A Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial. Front Immunol 2020; 11:2085. [PMID: 33013880 PMCID: PMC7506112 DOI: 10.3389/fimmu.2020.02085] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/30/2020] [Indexed: 01/08/2023] Open
Abstract
Background The hemostatic properties of tranexamic acid (TXA) are well described, but the immunological effects of TXA administration after traumatic injury have not been thoroughly examined. We hypothesized TXA would reduce monocyte activation in bleeding trauma patients with severe injury. Methods This was a single center, double-blinded, randomized controlled trial (RCT) comparing placebo to a 2 g or 4 g intravenous TXA bolus dose in trauma patients with severe injury. Fifty patients were randomized into each study group. The primary outcome was a reduction in monocyte activation as measured by human leukocyte antigen-DR isotype (HLA-DR) expression on monocytes 72 h after TXA administration. Secondary outcomes included kinetic assessment of immune and hemostatic phenotypes within the 72 h window post-TXA administration. Results The trial occurred between March 2016 and September 2017, when data collection ended. 149 patients were analyzed (placebo, n = 50; 2 g TXA, n = 49; 4 g TXA, n = 50). The fold change in HLA-DR expression on monocytes [reported as median (Q1–Q3)] from pre-TXA to 72 h post-TXA was similar between placebo [0.61 (0.51–0.82)], 2 g TXA [0.57 (0.47–0.75)], and 4 g TXA [0.57 (0.44–0.89)] study groups (p = 0.82). Neutrophil CD62L expression was reduced in the 4 g TXA group [fold change: 0.73 (0.63–0.97)] compared to the placebo group [0.97 (0.78–1.10)] at 24 h post-TXA (p = 0.034). The fold decrease in plasma IL-6 was significantly less in the 4 g TXA group [1.36 (0.87–2.42)] compared to the placebo group [0.46 (0.19–1.69)] at 72 h post-TXA (p = 0.028). There were no differences in frequencies of myeloid or lymphoid populations or in classical complement activation at any of the study time points. Conclusion In trauma patients with severe injury, 4 g intravenous bolus dosing of TXA has minimal immunomodulatory effects with respect to leukocyte phenotypes and circulating cytokine levels. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT02535949.
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Affiliation(s)
- Philip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Kimberly A Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Isaiah R Turnbull
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Anja Fuchs
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Kelly Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Douglas Schuerer
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Stacey Reese
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Adrian A Coleoglou Centeno
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Christopher B Horn
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Jack Baty
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, United States
| | - Susan M Shea
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - M Adam Meledeo
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Anthony E Pusateri
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, United States
| | - Andrew P Cap
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, United States
| | - Grant V Bochicchio
- Section of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
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24
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Quine EJ, Murray L, Trapani T, Cooper DJ. Thromboelastography to Assess Coagulopathy in Traumatic Brain Injury Patients Undergoing Therapeutic Hypothermia. Ther Hypothermia Temp Manag 2020; 11:53-57. [PMID: 32833584 DOI: 10.1089/ther.2020.0025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Therapeutic hypothermia has been a treatment option for patients with severe traumatic brain injury (TBI) for many years. There has, however, been uncertainty whether hypothermia in this context also increased clinical bleeding risk, perhaps due to platelet dysfunction. Standard coagulation tests do not allow accurate assessment of in vivo coagulation. We studied specific coagulation abnormalities in patients undergoing therapeutic hypothermia for severe TBI using bedside thromboelastography (TEG).We studied 20 patients with severe blunt TBI from a single tertiary ICU who were enrolled in the prophylactic hypothermia to lessen traumatic brain injury (POLAR) trial. Ten patients had been randomized to hypothermia, and 10 were controls receiving normothermic standard care. TEG was undertaken during and after therapeutic hypothermia, and at the same time points in controls. Coagulation profiles were then compared between the hypothermic and control patients, and also between hypothermia and later normothermia in the study patients. Patients were primarily young (mean age 34 years) and male (85%). Measures of injury severity, including Glasgow coma score and injury severity scale, were not different between groups. Using TEG, the median alpha angle was reduced in hypothermic patients compared with controls (69.2° vs. 72.0°, p = 0.02), although both were within the normal range. LY30 was also reduced (0.0% vs. 0.5%, p < 0.01). Both differences persisted when hypothermic patients were compared with themselves during later normothermia. Therapeutic hypothermia during severe TBI causes a small decrease in the rate of clot formation. However, this decrease is within the normal range, and is unlikely to be clinically significant.
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Affiliation(s)
- Edward J Quine
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Lynnette Murray
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.,Department of Intensive Care, Alfred Health, Melbourne, Australia
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25
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Lampridou M, Sokou R, Tsantes AG, Theodoraki M, Konstantinidi A, Ioakeimidis G, Bonovas S, Politou M, Valsami S, Iliodromiti Z, Boutsikou T, Iacovidou N, Nikolopoulos G, Tsantes AE. ROTEM diagnostic capacity for measuring fibrinolysis in neonatal sepsis. Thromb Res 2020; 192:103-108. [DOI: 10.1016/j.thromres.2020.05.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 04/23/2020] [Accepted: 05/18/2020] [Indexed: 02/06/2023]
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26
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Gopal JP, Dor FJMF, Crane JS, Herbert PE, Papalois VE, Muthusamy ASR. Anticoagulation in simultaneous pancreas kidney transplantation - On what basis? World J Transplant 2020; 10:206-214. [PMID: 32844096 PMCID: PMC7416362 DOI: 10.5500/wjt.v10.i7.206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/26/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite technical refinements, early pancreas graft loss due to thrombosis continues to occur. Conventional coagulation tests (CCT) do not detect hypercoagulability and hence the hypercoagulable state due to diabetes is left untreated. Thromboelastogram (TEG) is an in-vitro diagnostic test which is used in liver transplantation, and in various intensive care settings to guide anticoagulation. TEG is better than CCT because it is dynamic and provides a global hemostatic profile including fibrinolysis.
AIM To compare the outcomes between TEG and CCT (prothrombin time, activated partial thromboplastin time and international normalized ratio) directed anticoagulation in simultaneous pancreas and kidney (SPK) transplant recipients.
METHODS A single center retrospective analysis comparing the outcomes between TEG and CCT-directed anticoagulation in SPK recipients, who were matched for donor age and graft type (donors after brainstem death and donors after circulatory death). Anticoagulation consisted of intravenous (IV) heparin titrated up to a maximum of 500 IU/h based on CCT in conjunction with various clinical parameters or directed by TEG results. Graft loss due to thrombosis, anticoagulation related bleeding, radiological incidence of partial thrombi in the pancreas graft, thrombus resolution rate after anticoagulation dose escalation, length of the hospital stays and, 1-year pancreas and kidney graft survival between the two groups were compared.
RESULTS Seventeen patients who received TEG-directed anticoagulation were compared against 51 contemporaneous SPK recipients (ratio of 1: 3) who were anticoagulated based on CCT. No graft losses occurred in the TEG group, whereas 11 grafts (7 pancreases and 4 kidneys) were lost due to thrombosis in the CCT group (P = 0.06, Fisher’s exact test). The overall incidence of anticoagulation related bleeding (hematoma/ gastrointestinal bleeding/ hematuria/ nose bleeding/ re-exploration for bleeding/ post-operative blood transfusion) was 17.65% in the TEG group and 45.10% in the CCT group (P = 0.05, Fisher’s exact test). The incidence of radiologically confirmed partial thrombus in pancreas allograft was 41.18% in the TEG and 25.50% in the CCT group (P = 0.23, Fisher’s exact test). All recipients with partial thrombi detected in computed tomography (CT) scan had an anticoagulation dose escalation. The thrombus resolution rates in subsequent scan were 85.71% and 63.64% in the TEG group vs the CCT group (P = 0.59, Fisher’s exact test). The TEG group had reduced blood product usage {10 packed red blood cell (PRBC) and 2 fresh frozen plasma (FFP)} compared to the CCT group (71 PRBC/ 10 FFP/ 2 cryoprecipitate and 2 platelets). The proportion of patients requiring transfusion in the TEG group was 17.65% vs 39.25% in the CCT group (P = 0.14, Fisher’s exact test). The median length of hospital stay was 18 days in the TEG group vs 31 days in the CCT group (P = 0.03, Mann Whitney test). The 1-year pancreas graft survival was 100% in the TEG group vs 82.35% in the CCT group (P = 0.07, log rank test) and, the 1-year kidney graft survival was 100% in the TEG group vs 92.15% in the CCT group (P = 0.23, log tank test).
CONCLUSION TEG is a promising tool in guiding judicious use of anticoagulation with concomitant prevention of graft loss due to thrombosis, and reduces the length of hospital stay.
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Affiliation(s)
- Jeevan Prakash Gopal
- Imperial College Renal and Transplant Center, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, United Kingdom
| | - Frank JMF Dor
- Imperial College Renal and Transplant Center, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, United Kingdom
- Department of Surgery and Cancer, Imperial College, London W12 0HS, United Kingdom
| | - Jeremy S Crane
- Imperial College Renal and Transplant Center, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, United Kingdom
- Department of Surgery and Cancer, Imperial College, London W12 0HS, United Kingdom
| | - Paul E Herbert
- Imperial College Renal and Transplant Center, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, United Kingdom
- Department of Surgery and Cancer, Imperial College, London W12 0HS, United Kingdom
| | - Vassilios E Papalois
- Imperial College Renal and Transplant Center, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, United Kingdom
- Department of Surgery and Cancer, Imperial College, London W12 0HS, United Kingdom
| | - Anand SR Muthusamy
- Imperial College Renal and Transplant Center, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0HS, United Kingdom
- Department of Surgery and Cancer, Imperial College, London W12 0HS, United Kingdom
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27
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Zhao H, Cai X, Liu N, Zhang Z. Thromboelastography as a tool for monitoring blood coagulation dysfunction after adequate fluid resuscitation can predict poor outcomes in patients with septic shock. J Chin Med Assoc 2020; 83:674-677. [PMID: 32433347 DOI: 10.1097/jcma.0000000000000345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Coagulation abnormalities are universal in patients with septic shock and likely play a key role in multiple organ dysfunction syndrome. Early diagnosis and management of sepsis-induced coagulopathy can influence the outcome. Thromboelastography (TEG) can effectively distinguish hypercoagulability and hypocoagulability in patients with septic shock. TEG may be a useful tool to objectively evaluate the degree and risk of sepsis. METHODS A total of 76 adult patients with septic shock were enrolled and divided into four groups: patients with hypotension requiring vasopressor and serum lactate level >2 mmol/L (group A), patients with hypotension requiring vasopressor and serum lactate level ≤2 mmol/L (group B), patients with mean arterial pressure ≥65 mmHg and serum lactate level >2 mmol/L (group C), and patients with mean arterial pressure ≥65 mmHg and serum lactate level ≤2 mmol/L (group D) after adequate fluid resuscitation. TEG values were obtained at the emergency room and after 6 hours of adequate fluid resuscitation. Data on fibrinogen (FIB) levels, international normalized ratio (INR), activated partial thromboplastin time (aPTT), blood gas, platelet count, and D-dimers were also collected. RESULTS The length of stay in the intensive care unit was 9.11 ± 5.36 days. Mortality rate was 6.58%. The values of reaction time, kinetics time, maximum amplitude, alpha angle, aPTT, INR, serum creatinine, FIB, and sepsis-related organ failure assessment (SOFA) score showed a significant differences. The results of the routine coagulation tests, blood gas volume, platelet count, procalcitonin level, D-dimer level, white blood cell count, creatinine level, disseminated intravascular coagulation score, SOFA score, and TEG values after adequate fluid resuscitation were significantly different between groups A and B, groups A and C, groups A and D, groups B and D, and groups C and D. CONCLUSION TEG is helpful in predicting the severity of sepsis and outcome of patients.
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Affiliation(s)
- Hui Zhao
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiujun Cai
- Department of General Surgery Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ning Liu
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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28
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Scala E, Coutaz C, Gomez F, Alberio L, Marcucci C. Comparison of ROTEM Sigma to Standard Laboratory Tests and Development of an Algorithm for the Management of Coagulopathic Bleeding in a Tertiary Center. J Cardiothorac Vasc Anesth 2020; 34:640-649. [DOI: 10.1053/j.jvca.2019.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/03/2019] [Accepted: 10/07/2019] [Indexed: 01/17/2023]
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29
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Richards JE, Samet RE, Koerner AK, Grissom TE. Tranexamic Acid in the Perioperative Period: Yes, No, Maybe? Adv Anesth 2019; 37:87-110. [PMID: 31677661 DOI: 10.1016/j.aan.2019.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Ron E Samet
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - A Kennedy Koerner
- Department of Anesthesiology, University of Maryland School of Medicine, Center for the Sustainment of Trauma and Readiness Skills (CSTARS)-Baltimore, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA.
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30
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Peng HT, Nascimento B, Tien H, Callum J, Rizoli S, Rhind SG, Beckett A. A comparative study of viscoelastic hemostatic assays and conventional coagulation tests in trauma patients receiving fibrinogen concentrate. Clin Chim Acta 2019; 495:253-262. [DOI: 10.1016/j.cca.2019.04.066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/27/2019] [Accepted: 04/15/2019] [Indexed: 12/13/2022]
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31
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Farrell M, Marconi T, Getchell J, Green R, Cipolle M, Sixta S. The “Death Diamond”: Death beyond Trauma. Am Surg 2019. [DOI: 10.1177/000313481908500738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thromboelastography (TEG) has become a critical tool for the diagnosis, assessment, and management of hyperfibrinolysis and coagulopathy in trauma. In 2015, Chapman et al. of the Denver group coined the term “Death Diamond” (DD) to describe a TEG tracing identified in a unique trauma population. The DD was associated with a 100 per cent positive predictive value for mortality. Given the potential prognostic implications and resource savings associated with validating the DD as a marker of futile care, we sought to further evaluate DD outcomes. A retrospective review of 6850 TEGs, 34 patients (24 trauma and 10 nontrauma), displayed a DD tracing. Through invasive procedures and transfusions, nine DD tracing “normalized,” but, ultimately, this did not impact the outcome because the DD had a positive predictive value of 100 per cent for mortality in both populations. The median survival time in trauma patients was two hours compared with seven hours in nontrauma patients. Overall, this study further validates the predictive value of the DD in a trauma population while also serving as an assessment of the DD in a nontrauma population. Given these findings, a DD may prove to be an indicator of futile care. Further multicenter studies should be conducted to confirm these results.
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Affiliation(s)
- Michael Farrell
- Department of General Surgery, Christiana Care Health System, Newark, Delaware
| | - Thomas Marconi
- Department of General Surgery, Christiana Care Health System, Newark, Delaware
| | - John Getchell
- Department of General Surgery, Christiana Care Health System, Newark, Delaware
| | - Raymond Green
- Department of General Surgery, Christiana Care Health System, Newark, Delaware
| | - Mark Cipolle
- Department of General Surgery, Christiana Care Health System, Newark, Delaware
| | - Sherry Sixta
- Department of General Surgery, Christiana Care Health System, Newark, Delaware
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32
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Goal-directed hemostatic resuscitation for trauma induced coagulopathy: Maintaining homeostasis. J Trauma Acute Care Surg 2019; 84:S35-S40. [PMID: 29334568 DOI: 10.1097/ta.0000000000001797] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Affiliation(s)
- David R King
- From the Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, and the Department of Surgery, Harvard Medical School - both in Boston; and the U.S. Army Special Operations Command, Ft. Bragg, NC
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34
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Govil D, Pal D. Point-of-care Testing of Coagulation in Intensive Care Unit: Role of Thromboelastography. Indian J Crit Care Med 2019; 23:S202-S206. [PMID: 31656379 PMCID: PMC6785812 DOI: 10.5005/jp-journals-10071-23253] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Govil D, Pal D. Point-of-care Testing of Coagulation in Intensive Care Unit: Role of Thromboelastography. Indian J Crit Care Med 2019;23(Suppl 3):S202–S206.
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Affiliation(s)
- Deepak Govil
- Department of Critical Care Medicine, Medanta: The Medicity, Gurugram, Haryana, India
| | - Divya Pal
- Department of Critical Care Medicine, Medanta: The Medicity, Gurugram, Haryana, India
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Gomez-Builes JC, Acuna SA, Nascimento B, Madotto F, Rizoli SB. Harmful or Physiologic: Diagnosing Fibrinolysis Shutdown in a Trauma Cohort With Rotational Thromboelastometry. Anesth Analg 2018; 127:840-849. [PMID: 29683829 PMCID: PMC6135473 DOI: 10.1213/ane.0000000000003341] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Despite its central role in early trauma coagulopathy, abnormal fibrinolysis continues to be poorly understood. Excessive fibrinolysis is a known contributor to mortality. Recent studies with thromboelastography (TEG) suggest decreased fibrinolysis (or shutdown) may be just as harmful. Considering the broad use of 2 different viscoelastic assays, which are not interchangeable, we proposed for the first time to define and characterize fibrinolysis shutdown using rotational thromboelastometry (ROTEM). METHODS Retrospective cohort study of severely injured patients with admission ROTEM. Shutdown was defined by the best Youden index value of the maximum lysis. Fibrinolysis phenotypes were physiologic, hyperfibrinolysis, and shutdown. Multivariable logistic regression evaluated association between Injury Severity Score and the fibrinolysis phenotypes, and the association among shutdown phenotype with mortality, blood transfusion, and thrombotic events. RESULTS Five hundred fifty patients were included. Maximum lysis <3.5% was selected to define shutdown. Predominant phenotype was physiologic (70.7%), followed by shutdown (25.6%) and hyperfibrinolysis (3.6%). Shutdown patients had higher Injury Severity Score, lower base excess, and required more transfusions than physiologic group. Shutdown was associated with acidosis (base excess: odds ratio [OR] for a 1 mEq/L increase, 0.93; 95% confidence interval [CI], 0.88-0.98; P = .0094) and the combination of clotting derangements, higher clot firmness (maximum clot formation: OR for a 2 mm increase, 1.8; 95% CI, 1.5-2.27; P < .0001), lower fibrinogen (OR for a 0.5 g/dL decrease, 1.47; 95% CI, 1.18-1.84; P = .0006), and poor clot formation dynamics (clot formation time: OR for a 5 seconds increase, 1.25; 95% CI, 1.15-1.36; P < .0001). Fibrinolysis shutdown was not independently associated with mortality (OR, 0.61; 95% CI, 0.28-1.33; P = .21), massive transfusion (OR, 2.14; 95% CI, 0.79-5.74; P = .1308), or thrombotic events (OR, 1.08; 95% CI, 0.37-3.15; P = .874). Shutdown was associated with increased 24-hour transfusion (OR, 2.24; 95% CI, 1.24-4.04; P = .007). CONCLUSIONS Despite higher injury burden, evidence of shock, and greater need for blood transfusions, early fibrinolysis shutdown was not associated with mortality, suggesting that it could represent an adaptive physiologic response to life-threatening trauma.
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Affiliation(s)
- J. Carolina Gomez-Builes
- From the Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Sergio A. Acuna
- Department of Surgery, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Bartolomeu Nascimento
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Fabiana Madotto
- Department of Medicine and Surgery, Research Center on Public Health, University of Milano-Bicocca, Monza, Italy
| | - Sandro B. Rizoli
- From the Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Surgery, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Harrison MF. The Misunderstood Coagulopathy of Liver Disease: A Review for the Acute Setting. West J Emerg Med 2018; 19:863-871. [PMID: 30202500 PMCID: PMC6123093 DOI: 10.5811/westjem.2018.7.37893] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 07/08/2018] [Accepted: 07/14/2018] [Indexed: 12/13/2022] Open
Abstract
The international normalized ratio (INR) represents a clinical tool to assess the effectiveness of vitamin-K antagonist therapy. However, it is often used in the acute setting to assess the degree of coagulopathy in patients with hepatic cirrhosis or acute liver failure. This often influences therapeutic decisions about invasive procedures or the need for potentially harmful and unnecessary transfusions of blood product. This may not represent a best-practice or evidence-based approach to patient care. The author performed a review of the literature related to the utility of INR in cirrhotic patients using several scientific search engines. Despite the commonly accepted dogma that an elevated INR in a cirrhotic patient corresponds with an increased hemorrhagic risk during the performance of invasive procedures, the literature does not support this belief. Furthermore, the need for blood-product transfusion prior to an invasive intervention is not supported by the literature, as this practice increases the risk of complications associated with a patient's hospital course. Many publications ranging from case studies to meta-analyses refute this evidence and provide examples of thrombotic events despite elevated INR values. Alternative methods, such as thromboelastogram, represent alternate means of assessing in vivo risk of hemorrhage in patients with acute or chronic liver disease in real-time in the acute setting.
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Affiliation(s)
- Michael F Harrison
- Henry Ford Hospital, Department of Emergency Medicine, Department of Internal Medicine, Department of Critical Care Medicine, Detroit, Michigan
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Kim JS, Wang IJ, Yeom SR, Cho SJ, Kim JH, Seok JP, Lee SH, Bae BG, Min MK. Usefulness of Rotational Thromboelastometry as a Mortality Predictor of Hyperfibrinolysis in Patients with Severe Trauma. Acute Crit Care 2018; 33:162-169. [PMID: 31723880 PMCID: PMC6786692 DOI: 10.4266/acc.2018.00199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/02/2018] [Accepted: 08/17/2018] [Indexed: 12/30/2022] Open
Abstract
Background Hemorrhage is the major cause of traumatic death and the leading cause of preventable death. Hyperfibrinolysis is associated with trauma severity. Viscoelastic hemostatic assays show complete clot formation dynamics. The present study was designed to identify the relationship between hyperfibrinolysis and mortality, metabolic acidosis, and coagulopathy in patients with trauma. Methods Patients with severe trauma (injury severity score [ISS] of 15 or higher) who were assessed using rotational thromboelastometry (ROTEM) were included in the present study from January 2017 to December 2017. Variables were obtained from the Korea Trauma Database or the medical charts of the patients. To identify whether hyperfibrinolysis is an independent predictor of mortality, univariate and multivariate Cox regression analyses were performed. Results During the 1-year study period, 190 patients were enrolled. In total, 21 (11.1%) had hyperfibrinolysis according to the ROTEM analysis and 46 (24.2%) died. Patients with hyperfibrinolysis had a higher ISS (P=0.014) and mortality rate (P<0.001) than did those without hyperfibrinolysis. In multivariate Cox analysis, hyperfibrinolysis (hazard ratio [HR], 4.960; 95% confidence interval [CI], 2.447 to 10.053), age (HR, 1.033; 95% CI, 1.013 to 1.055), lactic acid level (HR, 1.085; 95% CI, 1.003 to 1.173), and ISS (HR, 1.037; 95% CI, 1.004 to 1.071) were independent predictors of mortality. Conclusions Hyperfibrinolysis is associated with increased mortality, worse metabolic acidosis, and severe coagulopathy and is an independent predictor of mortality in patients with trauma.
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Affiliation(s)
- Ji Soo Kim
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Il Jae Wang
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Seok Ran Yeom
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Suck Ju Cho
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Jae Hun Kim
- Department of Trauma Surgery, Pusan National University Hospital, Busan, Korea
| | - June Pill Seok
- Department of Trauma Surgery, Pusan National University Hospital, Busan, Korea
| | - Seong Hwa Lee
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Byung Gwan Bae
- Department of Emergency Medicine, Pusan National University Hospital, Busan, Korea
| | - Mun Ki Min
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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Ducloy-Bouthors AS, Duhamel A, Kipnis E, Tournoys A, Prado-Dupont A, Elkalioubie A, Jeanpierre E, Debize G, Peynaud-Debayle E, DeProst D, Huissoud C, Rauch A, Susen S. Postpartum haemorrhage related early increase in D-dimers is inhibited by tranexamic acid: haemostasis parameters of a randomized controlled open labelled trial. Br J Anaesth 2018; 116:641-8. [PMID: 27106967 DOI: 10.1093/bja/aew021] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Beneficial effects of tranexamic acid (TA) have been established in surgery and trauma. In ongoing postpartum haemorrhage (PPH), a moderate reduction of blood loss was observed in a previously published randomized controlled trial. Analysis of haemostasis parameters obtained from samples collected as part of this study are presented. METHODS Women with PPH >800 ml after vaginal delivery were assigned to receive either TA (4 g over 1 h, then 1 g per h over six h) (TA) or not (H). A non-haemorrhagic group (NH), <800 ml blood loss, was included as postpartum reference. At four time-points (enrolment, +30 min, +2 h, +6 h), haemostasis was assessed. Haemostasis assays were performed blinded to group allocation. Data were expressed as median [interquartiles] and compared with non-parametric tests. RESULTS In H compared with NH group, D-dimers increase (3730 ng ml(-1) [2468-8493] vs 2649 [2667-4375]; P=0.0001) and fibrinogen and factor II decrease were observed at enrolment and became maximal 2 h later. When comparing TA to H patients, the increase in Plasmin-Antiplasmin-complexes at +30 min (486 ng ml(-1) [340-1116] vs 674 [548-1640]; P=0.03) and D-dimers at +2 h (3888 ng ml(-1) [2688-6172] vs 7495 [4400-15772]; P=0.0001) was blunted. TA had no effect on fibrinogen decrease. CONCLUSIONS This study provides biological evidence of an early increase in D-dimers and plasmin-antiplasmin complexes associated with active post-partum haemorrhage and its attenuation by the early use of a clinically effective high dose of TA, opening the perspective of dose ranging studies to determinate the optimal dose and timing in this setting. CLINICAL TRIAL REGISTRATION ISRCTN09968140.
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Affiliation(s)
| | - A Duhamel
- Pole de Santé Publique, CHU Lille, Lille, France EA2694, Université of Lille Nord de France, France
| | - E Kipnis
- Pole d'Anesthésie-Réanimation, CHU Lille, France
| | - A Tournoys
- Hématologie Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, France Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France
| | - A Prado-Dupont
- Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France Pole d'hématologie, Maternité Monaco, Centre hospitalier, Valenciennes, France
| | - A Elkalioubie
- Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France
| | - E Jeanpierre
- Hématologie Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, France Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France
| | - G Debize
- Pole d'hématologie, Hôpital de la Croix Rousse, Hôpitaux civils Lyon, Lyon, France
| | - E Peynaud-Debayle
- APHP, Hôpital Louis Mourier, Service d'Hématologie Biologique, F-92701 Colombes, France
| | - D DeProst
- APHP, Hôpital Louis Mourier, Service d'Hématologie Biologique, F-92701 Colombes, France University Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France
| | - C Huissoud
- Pole d'obstétrique, Hôpital de la Croix Rousse, Hôpitaux Civils Lyon, Lyon, France
| | - A Rauch
- Hématologie Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, France Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France
| | - S Susen
- Hématologie Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, France Inserm U1011, Laboratoire de Recherche J&K, Institut Pasteur de Lille, Faculté de Médecine - Pôle recherche, University of Lille Nord de France, EGID, Lille, France
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Levy JH, Koster A, Quinones QJ, Milling TJ, Key NS. Antifibrinolytic Therapy and Perioperative Considerations. Anesthesiology 2018; 128:657-670. [PMID: 29200009 PMCID: PMC5811331 DOI: 10.1097/aln.0000000000001997] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Fibrinolysis is a physiologic component of hemostasis that functions to limit clot formation. However, after trauma or surgery, excessive fibrinolysis may contribute to coagulopathy, bleeding, and inflammatory responses. Antifibrinolytic agents are increasingly used to reduce bleeding, allogeneic blood administration, and adverse clinical outcomes. Tranexamic acid is the agent most extensively studied and used in most countries. This review will explore the role of fibrinolysis as a pathologic mechanism, review the different pharmacologic agents used to inhibit fibrinolysis, and focus on the role of tranexamic acid as a therapeutic agent to reduce bleeding in patients after surgery and trauma.
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Affiliation(s)
- Jerrold H. Levy
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Andreas Koster
- Institute of Anesthesiology, Heart and Diabetes Center NRW, Bad Oeynhausen, Ruhr-University Bochum, Germany
| | - Quintin J. Quinones
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | | | - Nigel S. Key
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina, Chapel Hill, NC
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Holzmacher JL, Reynolds C, Patel M, Maluso P, Holland S, Gamsky N, Moore H, Acquista E, Carrick M, Amdur R, Hancock H, Metzler M, Dunn J, Sarani B. Platelet transfusion does not improve outcomes in patients with brain injury on antiplatelet therapy. Brain Inj 2018; 32:325-330. [PMID: 29341793 DOI: 10.1080/02699052.2018.1425804] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Platelet dysfunction following traumatic brain injury (TBI) is associated with worse outcomes. The efficacy of platelet transfusion to reverse antiplatelet medication (APM) remains unknown. Thrombelastography platelet mapping (TEG-PM) assesses platelet function. We hypothesize that platelet transfusion can reverse the effects of APM but does not improve outcomes following TBI. METHODS An observational study at six US trauma centres was performed. Adult patients on APM with CT evident TBI after blunt injury were enrolled. Demographics, brain CT and TEG-PM results before/after platelet transfusion, length of stay (LOS), and injury severity score (ISS) were abstracted. RESULTS Sixty six patients were enrolled (89% aspirin, 50% clopidogrel, 23% dual APM) with 23 patients undergoing platelet transfusion. Transfused patients had significantly higher ISS and admission CT scores. Platelet transfusion significantly reduced platelet inhibition due to aspirin (76.0 ± 30.2% to 52.7 ± 31.5%, p < 0.01), but had a non-significant impact on clopidogrel-associated inhibition (p = 0.07). Platelet transfusion was associated with longer length of stay (7.8 vs. 3.5 days, p < 0.01), but there were no differences in mortality. CONCLUSION Platelet transfusion significantly decreases platelet inhibition due to aspirin but is not associated with change in outcomes in patients on APM following TBI.
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Affiliation(s)
- Jeremy L Holzmacher
- a Center for Trauma and Critical Care, Department of Surgery , George Washington University , Washington , DC, USA
| | - Cassandra Reynolds
- b Department of Surgery , East Carolina University Brody School of Medicine , Greenville , NC
| | - Mayur Patel
- c Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Departments of Surgery, Neurosurgery, and Hearing and Speech Sciences, Section of Surgical Sciences , Vanderbilt Brain Institute, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center; Surgical Service, General Surgery Section, Nashville VA, Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs , Nashville , TN
| | - Patrick Maluso
- a Center for Trauma and Critical Care, Department of Surgery , George Washington University , Washington , DC, USA
| | - Seth Holland
- d Department of Surgery , San Antonio Military Medical Center , Fort Sam Houston , TX
| | - Nathaniel Gamsky
- a Center for Trauma and Critical Care, Department of Surgery , George Washington University , Washington , DC, USA
| | - Henry Moore
- e Department of Surgery , Carle Foundation Hospital , Urbana , IL
| | - Elizabeth Acquista
- f Department of Surgery , University of North Carolina At Chapel Hill , Chapel Hill , NC
| | - Matthew Carrick
- g Department of Surgery , Medical Center at Plano , Plano , TX
| | - Richard Amdur
- a Center for Trauma and Critical Care, Department of Surgery , George Washington University , Washington , DC, USA
| | - Heather Hancock
- d Department of Surgery , San Antonio Military Medical Center , Fort Sam Houston , TX
| | - Michael Metzler
- h Department of Surgery , Medical Center of The Rockies , Loveland , CO
| | - Julie Dunn
- h Department of Surgery , Medical Center of The Rockies , Loveland , CO
| | - Babak Sarani
- a Center for Trauma and Critical Care, Department of Surgery , George Washington University , Washington , DC, USA
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Howley IW, Haut ER, Jacobs L, Morrison JJ, Scalea TM. Is thromboelastography (TEG)-based resuscitation better than empirical 1:1 transfusion? Trauma Surg Acute Care Open 2018; 3:e000140. [PMID: 29766129 PMCID: PMC5887764 DOI: 10.1136/tsaco-2017-000140] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 11/08/2017] [Indexed: 01/10/2023] Open
Abstract
Thomboelastography (TEG) is a whole blood measure of coagulation which was originally described in the 1950s. However, it has only been in the last few decades that assays have become accessible and viable as a point-of-care test. Following the observation that hemorrhagic shock is associated with an intrinsic coagulopathy, TEG has been used as a method of diagnosing specific coagulation defects in order to direct individualized blood products resuscitation. An alternative transfusion strategy is the administration of fixed ratio products, a paradigm borne out of military experience. It is unknown which strategy is superior and this topic was debated at the 36th Annual Point/Counterpoint Acute Care Surgery Conference. The following article summarizes the discussants points of view along with a summary of the evidence.
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Affiliation(s)
- Isaac W Howley
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
| | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Lenwoth Jacobs
- Department of Traumatology and Emergency Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
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Huebner BR, Dorlac WC, Cribari C. Tranexamic Acid Use in Prehospital Uncontrolled Hemorrhage. Wilderness Environ Med 2018; 28:S50-S60. [PMID: 28601210 DOI: 10.1016/j.wem.2016.12.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/08/2016] [Accepted: 12/01/2016] [Indexed: 02/06/2023]
Abstract
The use of tranexamic acid (TXA) in the treatment of trauma patients was relatively unexplored until the landmark Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage-2 (CRASH-2) trial in 2010 demonstrated a reduction in mortality with the use of TXA. Although this trial was a randomized, double-blinded, placebo-controlled study incorporating >20,000 patients, numerous limitations and weaknesses have been described. As a result, additional studies have followed, delineating the potential risks and benefits of TXA administration. A systematic review of the literature to date reveals a mortality benefit of early (ideally <1 hour and no later than 3 hours after injury) TXA administration in the treatment of severely injured trauma patients (systolic blood pressure <90 mm Hg, heart rate >110). Combined with abundant literature showing a reduction in bleeding in elective surgery, the most significant benefit may be administration of TXA before the patient goes into shock. Those trials that failed to show a mortality benefit of TXA in the treatment of hemorrhagic shock acknowledged that most patients received blood products before TXA administration, thus confounding the results. Although the use of prehospital TXA in the severely injured trauma patient will become more clear with the trauma studies currently underway, the current literature supports the use of prehospital TXA in this high-risk population. We recommend considering a 1 g TXA bolus en route to definitive care in high-risk patients and withholding subsequent doses until hyperfibrinolysis is confirmed by thromboelastography.
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Affiliation(s)
- Benjamin R Huebner
- Department of Surgery, University of Cincinnati, Cincinnati, OH (Dr Huebner)
| | - Warren C Dorlac
- University of Colorado Health, Loveland, CO and Volunteer Clinical Faculty, Department of Surgery, University of Cincinnati, Cincinnati, OH (Dr Dorlac).
| | - Chris Cribari
- University of Colorado Health, Loveland, CO (Dr Cribari)
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Lilitsis E, Xenaki S, Athanasakis E, Papadakis E, Syrogianni P, Chalkiadakis G, Chrysos E. Guiding Management in Severe Trauma: Reviewing Factors Predicting Outcome in Vastly Injured Patients. J Emerg Trauma Shock 2018; 11:80-87. [PMID: 29937635 PMCID: PMC5994855 DOI: 10.4103/jets.jets_74_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Trauma is one of the leading causes of death worldwide, with road traffic collisions, suicides, and homicides accounting for the majority of injury-related deaths. Since trauma mainly affects young age groups, it is recognized as a serious social and economic threat, as annually, almost 16,000 posttrauma individuals are expected to lose their lives and many more to end up disabled. The purpose of this research is to summarize current knowledge on factors predicting outcome - specifically mortality risk - in severely injured patients. Development of this review was mainly based on the systematic search of PubMed medical library, Cochrane database, and advanced trauma life support Guiding Manuals. The research was based on publications between 1994 and 2016. Although hypovolemic, obstructive, cardiogenic, and septic shock can all be seen in multi-trauma patients, hemorrhage-induced shock is by far the most common cause of shock. In this review, we summarize current knowledge on factors predicting outcome - more specifically mortality risk - in severely injured patients. The main mortality-predicting factors in trauma patients are those associated with basic human physiology and tissue perfusion status, coagulation adequacy, and resuscitation requirements. On the contrary, advanced age and the presence of comorbidities predispose patients to a poor outcome because of the loss of physiological reserves. Trauma resuscitation teams considering mortality prediction factors can not only guide resuscitation but also identify patients with high mortality risk who were previously considered less severely injured.
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Affiliation(s)
- Emmanuel Lilitsis
- Department of Anesthesiology, University Hospital of Crete, Heraklion, Greece
| | - Sofia Xenaki
- Department of General Surgery, University Hospital of Crete, Heraklion, Greece
| | - Elias Athanasakis
- Department of General Surgery, University Hospital of Crete, Heraklion, Greece
| | | | - Pavlina Syrogianni
- Department of Anesthesiology, University Hospital of Crete, Heraklion, Greece
| | - George Chalkiadakis
- Department of General Surgery, University Hospital of Crete, Heraklion, Greece
| | - Emmanuel Chrysos
- Department of General Surgery, University Hospital of Crete, Heraklion, Greece
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Jeong YH, Bliden K, Shuldiner A, Tantry U, Gurbel P. Thrombin-induced platelet-fibrin clot strength: Relation to high on-clopidogrel platelet reactivity, genotype, and post-percutaneous coronary intervention outcomes. Thromb Haemost 2017; 111:713-24. [DOI: 10.1160/th13-08-0643] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 11/03/2013] [Indexed: 01/01/2023]
Abstract
SummaryThe relationship between thrombin-induced platelet-fibrin clot strength (MATHROMBIN), genotype and high on-treatment platelet reactivity (HPR) is unknown. The aim of this study is to assess the influence of MATHROMBIN measured by thrombelastography on HPR and long-term major adverse cardiovascular events (MACE) in percutaneous coronary intervention (PCI)-treated patients during aspirin and clopidogrel therapy. MATHROMBIN, platelet aggregation, genotype, and two-year MACE were assessed in 197 PCI-treated patients. HPR was defined as 5 µM ADP-induced PR46% measured by conventional aggregometry. Both high MATHROMBIN ( 68 mm) and CYP2C19*2 allele carriage were independently associated with ADP-induced platelet aggregation ([uni03B2] coefficient: 8.3% and 12.0%, respectively). The combination of CYP2C19*2 allele carriage and high MATHROMBIN increased the predictive value for the risk of HPR (odds ratio: 13.89; 95% confidence interval: 3.41 to 55.56; p < 0.001). MACE occurred in 25 patients (12.7%). HPR and high MATHROMBIN were both associated with MACE (hazard ratio: 3.09 and 2.24, respectively), and patients with both HPR and high MATHROMBIN showed an increased risk for MACE (adjusted hazard ratio: 5.56; 95% confidence interval: 1.85 to 16.67; p = 0.002). In conclusion, this is the first study to demonstrate that high platelet-fibrin clot strength is an independent determinant of HPR in PCI-treated patients. Combining the measurements of platelet aggregation and platelet-fibrin clot strength may enhance post-PCI risk stratification and deserves further study.
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Liou DZ, Ko A, Volod O, Barmparas G, Harada MY, Martin MJ, Salim A, Dhillon N, Thomsen GM, Ley EJ. Thromboelastography After Murine TBI and Implications of Beta-Adrenergic Receptor Knockout. Neurocrit Care 2017; 25:145-52. [PMID: 26666545 DOI: 10.1007/s12028-015-0223-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The source of coagulopathy in traumatic brain injury (TBI) is multifactorial and may include adrenergic stimulation. The aim of this study was to assess coagulopathy after TBI using thromboelastography (TEG), and to investigate the implications of β-adrenergic receptor knockout. METHODS Adult male wild type c57/bl6 (WT) and β1/β2-adrenergic receptor knockout (BKO) mice were assigned to either TBI (WT-TBI, BKO-TBI) or sham injury (WT-sham, BKO-sham). Mice assigned to TBI were subject to controlled cortical impact (CCI). At 24 h post-injury, whole blood samples were obtained and taken immediately for TEG. RESULTS At 24 h after injury, a trend toward increased fibrinolysis was seen in WT-TBI compared to WT-sham although this did not reach significance (EPL 8.1 vs. 0 %, p = 0.18). No differences were noted in fibrinolysis in BKO-TBI compared to BKO-sham (LY30 2.6 vs. 2.5 %, p = 0.61; EPL 3.4 vs. 2.9 %, p = 0.61). In addition BKO-TBI demonstrated increased clot strength compared to BKO-sham (MA 76.6 vs. 68.6, p = 0.03; G 18.2 vs. 11.3, p = 0.03). CONCLUSIONS In a mouse TBI model, WT mice sustaining TBI demonstrated a trend toward increased fibrinolysis at 24 h after injury while BKO mice did not. These findings suggest β-blockade may attenuate the coagulopathy of TBI and minimize progression of intracranial hemorrhage by reducing fibrinolysis and increasing clot strength.
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Affiliation(s)
- Douglas Z Liou
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA
| | - Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA
| | - Oksana Volod
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA
| | - Megan Y Harada
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA
| | - Matthew J Martin
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA
| | - Ali Salim
- Department of Surgery, Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Navpreet Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA
| | - Gretchen M Thomsen
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA.
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McDonald MM, Almaghrabi TS, Saenz DM, Cai C, Rahbar MH, Choi HA, Lee K, Grotta JC, Chang TR. Dual Antiplatelet Therapy Is Associated With Coagulopathy Detectable by Thrombelastography in Acute Stroke. J Intensive Care Med 2017; 35:68-73. [DOI: 10.1177/0885066617729644] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Thrombelastography (TEG) provides a global, dynamic measure of coagulation. We examined the effect of antiplatelet (AP) medications on coagulation in patients with acute stroke as measured by TEG. Methods: We reviewed prospectively collected data on patients presenting with acute ischemic stroke (AIS) and spontaneous intracerebral hemorrhage (ICH) between 2009 and 2014. Patient demographics and baseline TEG values were compared among 4 different drug use groups: aspirin only, clopidogrel only, both aspirin and clopidogrel, and no AP. Multivariable regression models were conducted to compare the differences in TEG components. Results: A total of 202 patients were included, 139 with AIS and 63 with ICH. Forty-eight (24%) patients were taking aspirin alone, 12 (6%) were taking clopidogrel, 16 (8%) dual AP, and 126 (62%) no AP. Dual AP use was associated with prolonged mean R (time to initiate clotting) of 5.5 minutes as compared to no AP use (4.6 minutes, P = .04). Additionally, mean maximal amplitude (MA; final clot strength) and angle (rate of clot formation) were decreased in the dual AP group (MA = 59.3 mm, angle = 57.8°) as compared to the no AP group (MA = 64.5 mm, angle = 64.5°; P = .04 and P = .01, respectively). Patients on single AP therapy (either aspirin or clopidogrel) did not differ from those on no AP therapy in any TEG parameters measured. Conclusion: Dual AP therapy is associated with a detectable coagulopathy which may have implications in the management of patients with AIS and hemorrhagic stroke. The effects of single AP therapy may not be demonstrated by TEG.
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Affiliation(s)
- Mark M. McDonald
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Tareq S. Almaghrabi
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Daniel M. Saenz
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Chunyan Cai
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Mohammad H. Rahbar
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - H. Alex Choi
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
- Department of Neurology, University of Texas Health Science Center at Houston, TX, USA
| | - Kiwon Lee
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
- Department of Neurology, University of Texas Health Science Center at Houston, TX, USA
| | | | - Tiffany R. Chang
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
- Department of Neurology, University of Texas Health Science Center at Houston, TX, USA
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The rate of deep vein thrombosis doubles in trauma patients with hypercoagulable thromboelastography. J Trauma Acute Care Surg 2017; 83:413-419. [PMID: 28598908 DOI: 10.1097/ta.0000000000001618] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) in trauma can occur in patients at low risk. Conventional coagulation tests do not predict VTE. Studies investigating thromboelastography (TEG) for VTE risk are conflicting and have not included routine surveillance to detect deep vein thrombosis (DVT). We undertook a prospective study of TEG to evaluate its utility in predicting VTE. METHODS We conducted a prospective cohort study on all adult trauma patients admitted to our Level I trauma center from 2013 to 2015. TEG was performed immediately on arrival to the trauma bay. Hypercoagulable TEG was defined as reaction time (R) below, angle (α) above, or maximum amplitude (MA) above reference ranges. All patients received mechanical and/or pharmacologic prophylaxis and were followed up for DVT with our ultrasound surveillance protocol. The primary outcome was lower-extremity DVT. After bivariate analysis of variables related to DVT, those with p values of 0.100 or less were included for multivariate logistic regression. RESULTS A total of 983 patients were evaluated with TEG on admission; of these, 684 (69.6%) received at least one surveillance ultrasound during the index admission. Lower-extremity DVT was diagnosed in 99 (14.5%) patients. Hypercoagulability based on admission TEG occurred in 582 (85.1%) patients. The lower-extremity DVT rate was higher in patients with hypercoagulable TEG than in those without hypercoagulable TEG (15.6% vs. 8%; p = 0.039). Multivariate analysis showed hypercoagulable TEG remained associated with DVT after adjustment for relevant covariates available at admission, with an odds ratio of 2.41 (95% confidence interval, 1.11-5.24; p = 0.026). CONCLUSION Most trauma patients were hypercoagulable at admission and remained at risk of developing DVT. The rate of DVT doubled in patients with hypercoagulable TEG indices despite prophylaxis. Beyond its current clinical roles, TEG is useful for assessing DVT risk, particularly in patients otherwise perceived to be at low risk. LEVEL OF EVIDENCE Prognostic study, level II.
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Abstract
Fibrinolytic dysregulation is an important mechanism in traumatic coagulopathy. It is an incompletely understood process that consists of a spectrum ranging from excessive breakdown (hyperfibrinolysis) and the shutdown of fibrinolysis. Both hyperfibrinolysis and shutdown are associated with excess mortality and post-traumatic organ failure. The pathophysiology appears to relate to endothelial injury and hypoperfusion, with several molecular markers identified in playing a role. Although there are no universally accepted diagnostic tests, viscoelastic studies appear to offer the greatest potential for timely identification of patients presenting with fibrinolytic dysregulation. Treatment is multimodal, involving prompt hemorrhage control and resuscitation, with controversy surrounding the use of antifibrinolytic drug therapy. This review presents the current evidence on the pathophysiology, diagnostic challenges, as well as the management of this hemostatic dysfunction. LEVEL OF EVIDENCE Level III.
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50
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Bommiasamy AK, Schreiber MA. Damage control resuscitation: how to use blood products and manage major bleeding in trauma. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- A. K. Bommiasamy
- Department of Surgery; Oregon Health & Science University; Portland OR USA
| | - M. A. Schreiber
- Department of Surgery; Oregon Health & Science University; Portland OR USA
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