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Bärnthaler T, Mahla E, Toth GG, Schuligoi R, Prüller F, Buschmann E, Heinemann A. Supplemental Fibrinogen Restores Platelet Inhibitor-Induced Reduction in Thrombus Formation without Altering Platelet Function: An In Vitro Study. Thromb Haemost 2020; 120:1548-1556. [PMID: 32772348 DOI: 10.1055/s-0040-1715445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND For patients treated with dual antiplatelet therapy, standardized drug-specific 3-to-7 day cessation is recommended prior to major surgery to reach sufficient platelet function recovery. Here we investigated the hypothesis that supplemental fibrinogen might mitigate the inhibitory effects of antiplatelet therapy. METHODS AND RESULTS To this end blood from healthy donors was treated in vitro with platelet inhibitors, and in vitro thrombus formation and platelet activation were assessed. Ticagrelor, acetylsalicylic acid, the combination of both, and tirofiban all markedly attenuated the formation of adherent thrombi, when whole blood was perfused through collagen-coated microchannels at physiological shear rates. Addition of fibrinogen restored in vitro thrombus formation in the presence of antiplatelet drugs and heparin. However, platelet activation, as investigated in assays of P-selectin expression and calcium flux, was not altered by fibrinogen supplementation. Most importantly, fibrinogen was able to restore in vitro thrombogenesis in patients on maintenance dual antiplatelet therapy after percutaneous coronary intervention. CONCLUSION Thus, our in vitro data support the notion that supplementation of fibrinogen influences the perioperative hemostasis in patients undergoing surgery during antiplatelet therapy by promoting thrombogenesis without significantly interfering with platelet activation.
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Affiliation(s)
- Thomas Bärnthaler
- Otto Loewi Research Center, Division of Pharmacology Medical University of Graz, Graz, Austria
| | - Elisabeth Mahla
- Division of Anaesthesiology for Cardiovascular and Thoracic Surgery and Intensive Care Medicine, Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Gabor G Toth
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Rufina Schuligoi
- Otto Loewi Research Center, Division of Pharmacology Medical University of Graz, Graz, Austria
| | - Florian Prüller
- Clinical Institute of Medical Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Eva Buschmann
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Akos Heinemann
- Otto Loewi Research Center, Division of Pharmacology Medical University of Graz, Graz, Austria
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Bolliger D, Lancé MD, Siegemund M. Point-of-Care Platelet Function Monitoring: Implications for Patients With Platelet Inhibitors in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:1049-1059. [PMID: 32807601 DOI: 10.1053/j.jvca.2020.07.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 12/13/2022]
Abstract
Although most physicians are comfortable managing the limited anticoagulant effect of aspirin, the recent administration of potent P2Y12 receptor inhibitors in patients undergoing cardiac surgery remains a dilemma. Guidelines recommend discontinuation of potent P2Y12 inhibitors 5- to- 7 days before surgery to reduce the risk of postoperative hemorrhage. Such a strategy might not be feasible before urgent surgery, due to ongoing myocardial ischemia or in patients at high risk for thromboembolic events. Recently, different point-of-care devices to assess functional platelet quality have become available for clinical use. The aim of this narrative review was to evaluate the implications and potential benefits of platelet function monitoring in guiding perioperative management and therapeutic options in patients treated with antiplatelets, including aspirin or P2Y12 receptor inhibitors, undergoing cardiac surgery. No objective superiority of one point-of-care device over another was found in a large meta-analysis. Their accuracy and reliability are generally limited in the perioperative period. In particular, preoperative platelet function testing has been used to assess platelet contribution to bleeding after cardiac surgery. However, predictive values for postoperative hemorrhage and transfusion requirements are low, and there is a significant variability between and within these tests. Further, platelet function monitoring has been used to optimize the preoperative waiting period after cessation of dual antiplatelet therapy before urgent cardiac surgery. Furthermore, studies assessing their value in therapeutic decisions in bleeding patients after cardiac surgery are scarce. A general and liberal use of perioperative platelet function testing is not yet recommended.
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Affiliation(s)
- Daniel Bolliger
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
| | - Marcus D Lancé
- Department of Anesthesiology, Intensive Care Unit and Perioperative Medicine, Weill-Cornell Medicine-Qatar, Hamad Medical Corporation, Doha, Qatar
| | - Martin Siegemund
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
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Roy A, Stanford S, Nunn S, Alves S, Sargant N, Rangarajan S, Smith EA, Bell J, Dayal S, Cecil T, Tzivanakis A, Kruzhkova I, Solomon C, Knaub S, Moran B, Mohamed F. Efficacy of fibrinogen concentrate in major abdominal surgery - A prospective, randomized, controlled study in cytoreductive surgery for pseudomyxoma peritonei. J Thromb Haemost 2020; 18:352-363. [PMID: 31654548 PMCID: PMC7027898 DOI: 10.1111/jth.14665] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/18/2019] [Accepted: 10/22/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei (PMP) is associated with excessive bleeding and acquired fibrinogen deficiency. Maintaining plasma fibrinogen may support hemostasis. OBJECTIVES To compare hemostatic efficacy and safety of human fibrinogen concentrate (HFC) vs cryoprecipitate as fibrinogen sources for bleeding patients with acquired fibrinogen deficiency undergoing PMP CRS. METHODS FORMA-05 was an off-label single-center, prospective, randomized, controlled phase 2 study. Patients undergoing PMP surgery with predicted intraoperative blood loss ≥2 L received human fibrinogen concentrate (HFC; 4 g) or cryoprecipitate (two pools of 5 units, containing approximately 4.0-4.6 g fibrinogen), repeated as needed. The primary endpoint was a composite of intraoperative and postoperative efficacy, graded using objective 4-point scales and adjudicated by an independent committee. RESULTS One hundred percent of patients receiving HFC (95% confidence interval: 83.9-100.0, n = 21) or cryoprecipitate (84.6-100.0, n = 22) achieved hemostatic success. HFC demonstrated noninferior efficacy (P = .0095; post hoc) and arrived in the operating room 46 minutes faster. There were significantly greater mean increases with HFC vs cryoprecipitate in plasma fibrinogen (0.78 vs 0.35 g/L; P < .0001) and FIBTEM A20 (3.33 vs 0.93 mm; P = .003). Factor XIII, factor VIII, and von Willebrand factor activity were maintained throughout surgery. Only red blood cells were transfused intraoperatively (median units: HFC group, 1.0; cryoprecipitate group, 0.5). Thromboembolic events were detected with cryoprecipitate only. Safety was otherwise comparable between groups. CONCLUSIONS Human fibrinogen concentrate was hemostatically efficacious in patients undergoing major abdominal PMP surgery, with a favorable safety profile. These results are relevant to other surgical settings where bleeding and acquired fibrinogen deficiency occur.
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Affiliation(s)
- Ashok Roy
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | | | - Sean Nunn
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Sue Alves
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Nigel Sargant
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Savita Rangarajan
- University Hospital Southampton NHS Foundation TrustUK
- KJ Somaiya AyurviharMumbaiIndia
| | | | - John Bell
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Sanjeev Dayal
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Tom Cecil
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | | | | | | | | | - Brendan Moran
- Basingstoke and North Hampshire HospitalBasingstokeUK
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Zanetto A, Senzolo M, Blasi A. Perioperative management of antithrombotic treatment. Best Pract Res Clin Anaesthesiol 2020; 34:35-50. [PMID: 32334786 DOI: 10.1016/j.bpa.2020.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/13/2019] [Accepted: 01/06/2020] [Indexed: 01/10/2023]
Abstract
End-stage liver disease is characterized by multiple and complex alterations of hemostasis that are associated with an increased risk of both bleeding and thrombosis. Liver transplantation further challenges the feeble hemostatic balance of patients with decompensated cirrhosis, and the management of antithrombotic treatment during and after transplant surgery, which is particularly difficult. Bleeding was traditionally considered the major concern during and early after surgery, but it is increasingly recognized that transplant recipients may also develop thrombotic complications. Pathophysiology of hemostatic complications during and after transplantation is multifactorial and includes pre-, intra-, and postoperative risk factors. Risk stratification is important, as it helps the identification of high-risk recipients in whom antithrombotic prophylaxis should be considered. In recipients who develop thrombosis during or after surgery, prompt treatment is indicated to prevent graft failure, retransplantation, and death.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Annabel Blasi
- Anesthesia Department, Hospital Clinic de Barcelona, Barcelona, Spain.
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Shams Hakimi C, Singh S, Hesse C, Jeppsson A. Effects of fibrinogen and platelet transfusion on coagulation and platelet function in bleeding cardiac surgery patients. Acta Anaesthesiol Scand 2019; 63:475-482. [PMID: 30511382 DOI: 10.1111/aas.13295] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/14/2018] [Accepted: 11/04/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Excessive bleeding is a significant problem in cardiac surgery. Fibrinogen and platelet concentrate transfusion are used clinically to improve haemostasis and reduce bleeding but little is known about their functional effects on coagulation and platelet function in patients with ongoing bleeding. METHODS Forty-two patients with ongoing bleeding after cardiac surgery were included in an observational study. Patients received either fibrinogen concentrate (n = 16), platelet concentrate (n = 12), or both fibrinogen and platelets (n = 14), median doses 2 g fibrinogen and 2 units platelets given at one occasion. Blood samples were collected before and after transfusion. Coagulation (clotting time and clot stability) was analysed with rotational thromboelastometry, and platelet function with impedance aggregometry. In addition, platelet count and fibrinogen concentration was measured. Chest drain output was measured before and after the transfusion. RESULTS Fibrinogen infusion resulted in an increase in fibrinogen concentration and clot stability (P = 0.001), but had no effect on platelet aggregation. Platelet transfusion did not significantly affect coagulation, but improved arachidonic acid- and TRAP-induced platelet aggregation (P = 0.017 and 0.034 respectively) and increased platelet count. Combined fibrinogen and platelet transfusion shortened clotting time (P = 0.005) and increased clot stability (P = 0.001), and improved arachidonic acid- and TRAP-induced platelet aggregation (P = 0.004 and 0.016 respectively), and increased fibrinogen concentration and platelet count. The median bleeding volume was 150 (25th-75th percentile 70-240) mL/h before, and 60 (40-110) mL/h after transfusion of fibrinogen and/or platelet concentrate (P < 0.001). CONCLUSION The results demonstrate improved coagulation and platelet function following fibrinogen and platelet transfusion in patients bleeding after cardiac surgery.
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Affiliation(s)
- Caroline Shams Hakimi
- Department of Molecular and Clinical Medicine, Institute of Medicine; Sahlgrenska Academy, University of Gothenburg; Gothenburg Sweden
| | - Sukhi Singh
- Department of Molecular and Clinical Medicine, Institute of Medicine; Sahlgrenska Academy, University of Gothenburg; Gothenburg Sweden
| | - Camilla Hesse
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine; Sahlgrenska Academy, University of Gothenburg; Gothenburg Sweden
- Department of Cardiothoracic Surgery; Sahlgrenska University Hospital; Gothenburg Sweden
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Wei A, Liao L, Xiang L, Yan J, Yang W, Nai G, Luo M, Deng D, Lin F. Congenital dysfibrinogenaemia assessed by whole blood thromboelastography. Int J Lab Hematol 2018; 40:459-465. [PMID: 29708302 DOI: 10.1111/ijlh.12827] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 02/27/2018] [Indexed: 12/17/2022]
Affiliation(s)
- A. Wei
- Department of Clinical Laboratory; The First Affiliated Hospital of Guangxi Medical University; Nanning Guangxi China
| | - L. Liao
- Department of Clinical Laboratory; The First Affiliated Hospital of Guangxi Medical University; Nanning Guangxi China
| | - L. Xiang
- Department of Clinical Laboratory; The First Affiliated Hospital of Guangxi Medical University; Nanning Guangxi China
| | - J. Yan
- Department of Clinical Laboratory; The First Affiliated Hospital of Guangxi Medical University; Nanning Guangxi China
| | - W. Yang
- Department of Clinical Laboratory; The First Affiliated Hospital of Guangxi Medical University; Nanning Guangxi China
- Department of Clinical Laboratory; Yi Yang Central Hospital; Yiyang Hunan China
| | - G. Nai
- Department of Hematology; The First Affiliated Hospital of Guangxi Medical University; Nanning Guangxi China
| | - M. Luo
- Department of Clinical Laboratory; The First Affiliated Hospital of Guangxi Medical University; Nanning Guangxi China
| | - D. Deng
- Department of Hematology; The First Affiliated Hospital of Guangxi Medical University; Nanning Guangxi China
| | - F. Lin
- Department of Clinical Laboratory; The First Affiliated Hospital of Guangxi Medical University; Nanning Guangxi China
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Bolliger D, Tanaka K. Fibrinogen—is it a universal haemostatic agent? Br J Anaesth 2016; 117:548-550. [DOI: 10.1093/bja/aew332] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Solomon C, Ranucci M, Hochleitner G, Schöchl H, Schlimp CJ. Assessing the Methodology for Calculating Platelet Contribution to Clot Strength (Platelet Component) in Thromboelastometry and Thrombelastography. Anesth Analg 2015; 121:868-878. [PMID: 26378699 PMCID: PMC4568902 DOI: 10.1213/ane.0000000000000859] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2015] [Indexed: 12/28/2022]
Abstract
The viscoelastic properties of blood clot have been studied most commonly using thrombelastography (TEG) and thromboelastometry (ROTEM). ROTEM-based bleeding treatment algorithms recommend administering platelets to patients with low EXTEM clot strength (e.g., clot amplitude at 10 minutes [A10] <40 mm) once clot strength of the ROTEM® fibrin-based test (FIBTEM) is corrected. Algorithms based on TEG typically use a low value of maximum amplitude (e.g., <50 mm) as a trigger for administering platelets. However, this parameter reflects the contributions of various blood components to the clot, including platelets and fibrin/fibrinogen. The platelet component of clot strength may provide a more sensitive indication of platelet deficiency than clot amplitude from a whole blood TEG or ROTEM® assay. The platelet component of the formed clot is derived from the results of TEG/ROTEM® tests performed with and without platelet inhibition. In this article, we review the basis for why this calculation should be based on clot elasticity (e.g., the E parameter with TEG and the CE parameter with ROTEM®) as opposed to clot amplitude (e.g., the A parameter with TEG or ROTEM®). This is because clot elasticity, unlike clot amplitude, reflects the force with which the blood clot resists rotation within the device, and the relationship between clot amplitude (variable X) and clot elasticity (variable Y) is nonlinear. A specific increment of X (ΔX) will be associated with different increments of Y (ΔY), depending on the initial value of X. When calculated correctly, using clot elasticity data, the platelet component of the clot can provide a valuable insight into platelet deficiency in emergency bleeding.
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Affiliation(s)
- Cristina Solomon
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Marco Ranucci
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Gerald Hochleitner
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Herbert Schöchl
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
| | - Christoph J. Schlimp
- From the CSL Behring, Marburg, Germany; Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria; Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico, San Donato, Milan, Italy; CSL Behring, Vienna, Austria and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Austria
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