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Hayes HV, Droege ME, Furnish CJ, Goodman MD, Ernst NE, Droege CA. Admission thrombelastography does not guide dose adjustment of enoxaparin in trauma patients. Surg Open Sci 2020; 2:41-44. [PMID: 33073224 PMCID: PMC7545004 DOI: 10.1016/j.sopen.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/12/2020] [Accepted: 03/25/2020] [Indexed: 11/14/2022] Open
Abstract
Background Enoxaparin is used as chemoprophylaxis to reduce incidence of venous thromboembolism and its complications following trauma. Serum anti-Xa monitoring is used to assess efficacy but requires several doses to be administered. Thrombelastography assesses hypercoagulability and may have utility identifying high-risk patients for venous thromboembolism. The objective was to evaluate whether thrombelastography parameters could identify trauma patients requiring enoxaparin dose adjustment earlier than serum anti-Xa concentrations. Methods A single-center, retrospective medical record review evaluated patients admitted to a regional level I trauma center that received an admission thrombelastography and a dose of enoxaparin with a serum trough anti-Xa concentration drawn. Patients were divided into standard-dose or dose-adjusted enoxaparin. Venous thromboembolism incidence between groups and risk factors for enoxaparin dose adjustment and venous thromboembolism development were evaluated. Results A total of 204 patients were included. Differences observed between groups included age (standard-dose enoxaparin, 48.5 [29.3–72] vs dose-adjusted enoxaparin, 38.5 [25–55.7] years; P = .005), admission creatinine clearance (standard-dose enoxaparin, 92.9 [67.4–113.4] vs dose-adjusted enoxaparin, 102.1 [83.8–129.2] mL/min; P = .017), and time to venous thromboembolism prophylaxis initiation (standard-dose enoxaparin, 23.8 [11.2–36.4] vs dose-adjusted enoxaparin, 34.5 [18.3–52.7] hours; P = .004). No differences in thrombelastography parameters or venous thromboembolism incidence were observed. No independent risk factors for enoxaparin dose adjustment were identified; however, risk assessment profile score > 10 was an independent risk factor for venous thromboembolism development. Conclusion No relationship between admission thrombelastography and need for enoxaparin dose adjustment in trauma patients was observed. As thrombelastography continues growing in clinical use, it is prudent to investigate other potential applications. Currently, thrombelastography should not be used to guide enoxaparin dosing. Admission thrombelastography does not predict need for enoxaparin dose adjustment. No thrombelastography parameter predicted need for dose adjustment. Physiologic criteria are better predictors of chemoprophylaxis pharmacodynamics. Risk assessment profile score > 10 continues to correlate with VTE risk in trauma patients.
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Affiliation(s)
- Hannah V Hayes
- University of Cincinnati Department of Surgery, Cincinnati, OH
| | - Molly E Droege
- UC Health-University of Cincinnati Medical Center Department of Pharmacy, Cincinnati, OH.,University of Cincinnati James L. Winkle College of Pharmacy, Division of Pharmacy Practice and Administrative Sciences, Cincinnati, OH
| | - Craig J Furnish
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | | | - Neil E Ernst
- UC Health-University of Cincinnati Medical Center Department of Pharmacy, Cincinnati, OH.,University of Cincinnati James L. Winkle College of Pharmacy, Division of Pharmacy Practice and Administrative Sciences, Cincinnati, OH
| | - Christopher A Droege
- UC Health-University of Cincinnati Medical Center Department of Pharmacy, Cincinnati, OH.,University of Cincinnati James L. Winkle College of Pharmacy, Division of Pharmacy Practice and Administrative Sciences, Cincinnati, OH
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Gangloff C, Mingant F, Theron M, Galinat H, Grimault O, Ozier Y, Pichavant-Rafini K. New considerations on pathways involved in acute traumatic coagulopathy: the thrombin generation paradox. World J Emerg Surg 2019; 14:57. [PMID: 31857822 PMCID: PMC6909491 DOI: 10.1186/s13017-019-0276-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/11/2019] [Indexed: 01/24/2023] Open
Abstract
Abstract Background An acute traumatic coagulopathy (ATC) is observed in about one third of severely traumatized patients. This early, specific, and endogenous disorder is triggered by the association of trauma and hemorrhage. The early phase of this condition is characterized by the expression of a bleeding phenotype leading to hemorrhagic shock and the late phase by a prothrombotic profile leading to multiple organ failure. The physiopathology of this phenomenon is still poorly understood. Hypotheses of disseminated intravascular coagulation, activated protein C-mediated fibrinolysis, fibrinogen consumption, and platelet functional impairment were developed by previous authors and continue to be debated. The objective of this study was to observe general hemostasis disorders in case of ATC to confront these hypotheses. Method Four groups of 15 rats were compared: C, control; T, trauma; H, hemorrhage; and TH, trauma and hemorrhage. Blood samples were drawn at baseline and 90 min. Thrombin generation tests, platelet aggregometry, and standard hemostasis tests were performed. Results Significant differences were observed between the baseline and TH groups for aPTT (17.9 ± 0.8 s vs 24.3 ± 1.4 s, p < 0.001, mean ± SEM), MAP (79.7 ± 1.3 mmHg vs 43.8 ± 1.3 mmHg, p < 0.001, mean ± SEM), and hemoglobin (16.5 ± 0.1 g/dL vs 14.1 ± 0.3 g/dL, p < 0.001, mean ± SEM), indicating the presence of an hemorrhagic shock due to ATC. Compared to all other groups, coagulation factor activities were decreased in the TH group, but endogenous thrombin potential was (paradoxically) higher than in group C (312 ± 17 nM/min vs. 228 ± 23 nM/min; p = 0.016; mean ± SEM). We also observed a subtle decrease in platelet count and function in case of ATC and retrieved an inversed linear relationship between fibrinogen concentration and aPTT (intercept, 26.53 ± 3.16; coefficient, − 3.40 ± 1.26; adjusted R2: 0.1878; p = 0.0123). Conclusions The clinical-biological profile that we observed, combining normal thrombin generation, fibrinogen depletion, and a hemorrhagic phenotype, reinforced the hypothesis of activated protein C mediated-fibrinolysis. The key role of fibrinogen, but not of the platelets, was confirmed in this study. The paradoxical preservation of thrombin generation suggests a protective mechanism mediated by rhabdomyolysis in case of major trauma. Based on these results, we propose a new conception concerning the pathophysiology of ATC.
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Affiliation(s)
- Cedric Gangloff
- 1ORPHY Laboratory EA4324, Université de Bretagne Occidentale, Brest, France.,2Department of Emergency Medicine, CHU Pontchaillou, Rennes, France
| | - Fanny Mingant
- Department of Biology and Hemostasis, CHRU Cavale Blanche, Brest, France
| | - Michael Theron
- 1ORPHY Laboratory EA4324, Université de Bretagne Occidentale, Brest, France
| | - Hubert Galinat
- Department of Biology and Hemostasis, CHRU Cavale Blanche, Brest, France
| | - Ollivier Grimault
- 1ORPHY Laboratory EA4324, Université de Bretagne Occidentale, Brest, France.,4Department of Emergency Medicine, Hôpital de la Cavale Blanche, Brest, France
| | - Yves Ozier
- 1ORPHY Laboratory EA4324, Université de Bretagne Occidentale, Brest, France.,5Department of Anaesthesiology, Hôpital de la Cavale Blanche, Brest, France
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Exposing the bidirectional effects of alcohol on coagulation in trauma: Impaired clot formation and decreased fibrinolysis in rotational thromboelastometry. J Trauma Acute Care Surg 2019; 84:97-103. [PMID: 29267182 DOI: 10.1097/ta.0000000000001716] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alcohol has been associated with altered viscoelastic testing in trauma, indicative of impaired coagulation. Such alterations, however, show no correlation to coagulopathy-related outcomes. Other data suggest that alcohol may inhibit fibrinolysis. We sought to clarify these mechanisms after traumatic injury using thromboelastometry (ROTEM), hypothesizing that alcohol-related clot formation impairment may be counter-balanced by inhibited fibrinolysis. METHODS Laboratory, demographic, clinical, and outcome data were prospectively collected from 406 critically injured trauma patients at a Level I trauma center. ROTEM and standard coagulation measures were conducted in parallel. Univariate comparisons were performed by alcohol level (EtOH), with subsequent regression analysis. RESULTS Among 274 (58%) patients with detectable EtOH, median EtOH was 229 mg/dL. These patients were primarily bluntly injured and had lower GCS (p < 0.05) than EtOH-negative patients, but had similar admission pH and injury severity (p = NS). EtOH-positive patients had prolonged ROTEM clotting time and rate of clot formation time (CFT/α); they also had decreased fibrinolysis (max lysis %; all p < 0.05). In linear regression, for every 100 mg/dL increase in EtOH, clotting time increased by 13 seconds and fibrinolysis decreased by 1.5% (both p < 0.05). However, EtOH was not an independent predictor of transfusion requirements or mortality. In high-EtOH patients with coagulopathic ROTEM tracings, transfusion rates were significantly lower than expected, relative to EtOH-negative patients with similar ROTEM findings. CONCLUSION As assayed by ROTEM, alcohol appears to have a bidirectional effect on coagulation in trauma, both impairing initial clot formation and inhibiting fibrinolysis. This balancing of mechanisms may explain lack of correlation between altered ROTEM and coagulopathy-related outcomes. Viscoelastic testing should be used with caution in intoxicated trauma patients. LEVEL OF EVIDENCE Epidemiological study, level III.
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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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Overexpression of miR-24 Is Involved in the Formation of Hypocoagulation State after Severe Trauma by Inhibiting the Synthesis of Coagulation Factor X. DISEASE MARKERS 2017; 2017:3649693. [PMID: 28694557 PMCID: PMC5488151 DOI: 10.1155/2017/3649693] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 04/16/2017] [Accepted: 05/14/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Dysregulation of microRNAs may contribute to the progression of trauma-induced coagulopathy (TIC). We aimed to explore the biological function that miRNA-24-3p (miR-24) might have in coagulation factor deficiency after major trauma and TIC. METHODS 15 healthy volunteers and 36 severe trauma patients (Injury Severity Score ≥ 16 were enrolled. TIC was determined as the initial international normalized ratio >1.5. The miR-24 expression and concentrations of factor X (FX) and factor XII in plasma were measured. In vitro study was conducted on L02 cell line. RESULTS The plasma miR-24 expression was significantly elevated by 3.17-fold (P = 0.043) in major trauma patients and reduced after 3 days (P < 0.01). The expression level was significantly higher in TIC than in non-TIC patients (P = 0.040). Multivariate analysis showed that the higher miR-24 expression was associated with TIC. The plasma concentration of FX in TIC patients was significantly lower than in the non-TIC ones (P = 0.030) and controls (P < 0.01). A negative correlation was observed between miR-24 and FX. miR-24 transduction significantly reduced the FX level in the supernatant of L02 cells (P = 0.030). CONCLUSIONS miR-24 was overexpressed in major trauma and TIC patients. The negative correlation of miR-24 with FX suggested the possibility that miR-24 might inhibit the synthesis of FX during TIC.
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Grottke O, Aisenberg J, Bernstein R, Goldstein P, Huisman MV, Jamieson DG, Levy JH, Pollack CV, Spyropoulos AC, Steiner T, Del Zoppo GJ, Eikelboom J. Efficacy of prothrombin complex concentrates for the emergency reversal of dabigatran-induced anticoagulation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:115. [PMID: 27125504 PMCID: PMC4850655 DOI: 10.1186/s13054-016-1275-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Dabigatran is effective in decreasing the risk of ischaemic stroke in patients with atrial fibrillation. However, like all anticoagulants, it is associated with a risk of bleeding. In cases of trauma or emergency surgery, emergency reversal of dabigatran-induced anticoagulation may be required. A specific reversal agent for dabigatran, idarucizumab, has been approved by the US Food and Drug Administration. Alternative reversal agents are available, such as prothrombin complex concentrates (PCCs) and activated PCCs (aPCCs). In this review we evaluate the role of PCCs and aPCCs in the reversal of dabigatran anticoagulation and consider which tests are appropriate for monitoring coagulation in this setting. Pre-clinical studies, small clinical studies and case reports indicate that PCCs and aPCCs may be able to reverse dabigatran-induced anticoagulation in a dose-dependent manner. However, dosing based on coagulation parameters can be difficult because available assays may not provide adequate sensitivity and specificity for measuring anticoagulation induced by dabigatran or the countering effects of PCCs/aPCCs. In addition, PCCs or aPCCs can potentially provoke thromboembolic complications. Despite these limitations and the fact that PCCs and aPCCs are not yet licensed for dabigatran reversal, their use appears to be warranted in patients with life-threatening haemorrhage if idarucizumab is not available.
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Affiliation(s)
- Oliver Grottke
- Department of Anesthesiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany.
| | - James Aisenberg
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard Bernstein
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Patrick Goldstein
- Emergency Department and SAMU, Lille University Hospital, Lille, France
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Dara G Jamieson
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Charles V Pollack
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alex C Spyropoulos
- Hofstra North Shore/LIJ School of Medicine, Lenox Hill Hospital, New York, NY, USA
| | | | - Gregory J Del Zoppo
- Departments of Medicine and Neurology, University of Washington, Seattle, WA, USA
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Howard BM, Kornblith LZ, Cheung CK, Kutcher ME, Miyazawa BY, Vilardi RF, Cohen MJ. Inducing Acute Traumatic Coagulopathy In Vitro: The Effects of Activated Protein C on Healthy Human Whole Blood. PLoS One 2016; 11:e0150930. [PMID: 27008408 PMCID: PMC4805205 DOI: 10.1371/journal.pone.0150930] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 02/22/2016] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Acute traumatic coagulopathy has been associated with shock and tissue injury, and may be mediated via activation of the protein C pathway. Patients with acute traumatic coagulopathy have prolonged PT and PTT, and decreased activity of factors V and VIII; they are also hypocoagulable by thromboelastometry (ROTEM) and other viscoelastic assays. To test the etiology of this phenomenon, we hypothesized that such coagulopathy could be induced in vitro in healthy human blood with the addition of activated protein C (aPC). METHODS Whole blood was collected from 20 healthy human subjects, and was "spiked" with increasing concentrations of purified human aPC (control, 75, 300, 2000 ng/mL). PT/PTT, factor activity assays, and ROTEM were performed on each sample. Mixed effect regression modeling was performed to assess the association of aPC concentration with PT/PTT, factor activity, and ROTEM parameters. RESULTS In all subjects, increasing concentrations of aPC produced ROTEM tracings consistent with traumatic coagulopathy. ROTEM EXTEM parameters differed significantly by aPC concentration, with stepwise prolongation of clotting time (CT) and clot formation time (CFT), decreased alpha angle (α), impaired early clot formation (a10 and a20), and reduced maximum clot firmness (MCF). PT and PTT were significantly prolonged at higher aPC concentrations, with corresponding significant decreases in factor V and VIII activity. CONCLUSION A phenotype of acute traumatic coagulopathy can be induced in healthy blood by the in vitro addition of aPC alone, as evidenced by viscoelastic measures and confirmed by conventional coagulation assays and factor activity. This may lend further mechanistic insight to the etiology of coagulation abnormalities in trauma, supporting the central role of the protein C pathway. Our findings also represent a model for future investigations in the diagnosis and treatment of acute traumatic coagulopathy.
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Affiliation(s)
- Benjamin M. Howard
- Department of Surgery, University of California San Francisco and San Francisco General Hospital, San Francisco, California, United States of America
- * E-mail:
| | - Lucy Z. Kornblith
- Department of Surgery, University of California San Francisco and San Francisco General Hospital, San Francisco, California, United States of America
| | - Christopher K. Cheung
- Department of Surgery, University of California San Francisco and San Francisco General Hospital, San Francisco, California, United States of America
| | - Matthew E. Kutcher
- Department of Surgery, University of Pittsburgh Medical Center and Presbyterian University Hospital, Pittsburgh, Pennsylvania, United States of America
| | - Byron Y. Miyazawa
- Department of Surgery, University of California San Francisco and San Francisco General Hospital, San Francisco, California, United States of America
| | - Ryan F. Vilardi
- Department of Surgery, University of California San Francisco and San Francisco General Hospital, San Francisco, California, United States of America
| | - Mitchell J. Cohen
- Department of Surgery, University of California San Francisco and San Francisco General Hospital, San Francisco, California, United States of America
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Abstract
Trauma-induced coagulopathy (TIC) includes heterogeneous coagulopathic syndromes with different underlying causes, and treatment is challenged by limited diagnostic tests to discriminate between these entities in the acute setting. We provide an overview of progress in understanding the mechanisms of TIC and the context for several of the hypotheses that will be tested in 'TACTIC'. Although connected to ongoing clinical trials in trauma, TACTIC itself has no intent to conduct clinical trials. We do anticipate that 'early translation' of promising results will occur. Functions anticipated at this early translational level include: (i) basic science groundwork for future therapeutic candidates; (ii) development of acute coagulopathy scoring systems; (iii) coagulation factor composition-based computational analysis; (iv) characterization of novel analytes including tissue factor, polyphosphates, histones, meizothrombin and α-thrombin-antithrombin complexes, factor XIa, platelet and endothelial markers of activation, signatures of protein C activation and fibrinolysis markers; and (v) assessment of viscoelastic tests and new point-of-care methods.
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Affiliation(s)
- K G Mann
- Department of Biochemistry, University of Vermont, Colchester, VT, USA
| | - K Freeman
- Department of Surgery, University of Vermont, Burlington, VT, USA
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