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Yoshii R, Takahashi Y, Tanaka KA, Kawajiri H, Sawa T, Amaya F, Ogawa S. Point-of-care testing for tranexamic acid efficacy: a proof-of-concept study in cardiac surgical patients. Br J Anaesth 2024; 132:1211-1218. [PMID: 38677950 DOI: 10.1016/j.bja.2024.03.023] [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: 12/19/2023] [Revised: 03/03/2024] [Accepted: 03/08/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Low-dose tranexamic acid (TXA) has been recently recommended for cardiopulmonary bypass (CPB) to reduce associated complications. Although point-of-care laboratory tests for TXA concentrations are unavailable, a novel TPA-test on the ClotPro® system can measure TXA-induced inhibition of fibrinolysis. We evaluated the performance of the TPA-test in vitro and in patients undergoing surgery requiring CPB. METHODS Blood samples were obtained from six volunteers for in vitro evaluation of tissue plasminogen activator (tPA)-triggered fibrinolysis and the effects of TXA. This was followed by an observational study in 20 cardiac surgery patients to assess clinical effects of TXA on the TPA-test. RESULTS Hyperfibrinolysis induced by tPA was inhibited by TXA ≥2 mg L-1 in a concentration-dependent manner, and was completely inhibited at TXA ≥10 mg L-1. In patients undergoing CPB, antifibrinolytic effect was detectable on TPA-test parameters after a 0.1 g bolus of TXA at the end of CPB, and complete inhibition of fibrinolysis was obtained with TXA ≥0.5 g. The antifibrinolytic effects of 1 g TXA on TPA-test parameters were gradually attenuated over 18 h after surgery. However, the fibrinolytic inhibition continued in four patients with estimated glomerular filtration rate (eGFR) ≤30 ml min-1 1.73 m-2. The eGFR had strong correlations with TPA-test parameters at 18 h after surgery (r=0.86-0.92; P<0.0001). CONCLUSIONS The TPA-test is sensitive to low concentrations of TXA and serves as a practical monitoring tool for postoperative fibrinolytic activity in cardiac surgery patients. This test might be particularly useful in patients with severe renal impairment.
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Affiliation(s)
- Ryogo Yoshii
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuya Takahashi
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hidetake Kawajiri
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiji Sawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumimasa Amaya
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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Takahashi Y, Yoshii R, Amaya F, Sawa T, Ogawa S. Effect of acute normovolemic hemodilution in patients undergoing cardiac surgery with remimazolam anesthesia. J Anesth 2024; 38:98-104. [PMID: 38150014 DOI: 10.1007/s00540-023-03290-5] [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: 08/23/2023] [Accepted: 11/24/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE The reduced effects of allogeneic transfusion with acute normovolemic hemodilution (ANH) have been reported. Harvesting a large volume of blood may maximize the effect in patients with low body weight, and the prevention of hypotension is important. Remimazolam is an anesthetic with few circulatory responses. Our aim was to evaluate whether high-volume ANH reduces the need for transfusion in cardiac patients under remimazolam anesthesia. METHODS In this retrospective single-center study, we enrolled cardiopulmonary bypass (CPB) patients who received remimazolam anesthesia. Changes in hemodynamic parameters were assessed. The numbers of blood transfusions and chest tube outputs were also evaluated. RESULTS In a total of 51 patients, ANH was performed in 27 patients with a mean body mass index of 23.2 (ANH volume: 740 ± 222 mL). No significant differences were observed in mean blood pressure during blood collection. The intraoperative amount of red blood cell (RBC) transfusion was significantly lower in the ANH group than in the control group (431 ± 678 and 1260 ± 572 mL, p < 0.001). The avoidance rates of RBC were 66.7 and 4.2%, respectively. The multivariate analysis result revealed that ANH correlated with RBC, with an odds ratio of 0.067 (95% confidence interval 0.005-0.84, p < 0.05). The postoperative bleeding at 24 h was significantly lower in the ANH group (455 ± 228 and 797 ± 535 mL, p < 0.01). CONCLUSION In patients undergoing CPB, ANH reduced intraoperative transfusion amount and postoperative bleeding. Hemodynamic changes during blood collection were minimal under remimazolam anesthesia and high-volume ANH was feasible.
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Affiliation(s)
- Yuya Takahashi
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ryogo Yoshii
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumimasa Amaya
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566, Japan
| | - Teiji Sawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
- Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566, Japan.
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Omae T, Ishikawa T, Ogiwara K, Nogami K. Pediatric Mesangial Proliferative Glomerulonephritis Has Increased the Platelet Thrombus Formation Potentials under High-Shear Flow Condition. Nephron Clin Pract 2023; 148:415-425. [PMID: 37812914 DOI: 10.1159/000534494] [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: 06/13/2023] [Accepted: 09/26/2023] [Indexed: 10/11/2023] Open
Abstract
INTRODUCTION Blood coagulation is associated with glomerulonephritis (GN) pathophysiology. Using whole-blood-based rotational thromboelastometry, we recently reported that the degree of hypercoagulability in pediatric patients with immunoglobulin A nephropathy (IgAN), a GN, might be associated with pathological severity. To further clarify the coagulation status of mesangial proliferative GN (MesPGN), we assessed the platelet thrombus formation (PTF) under high-shear flow using a microchip-based flow chamber system (T-TAS®). METHODS Thirty-four pediatric patients definitively diagnosed with MesPGN by renal biopsy at Nara Medical University Hospital between 2015 and 2022 were enrolled, and 29 patients (case group; median age, 8.0 years) were assessed. Microchips coated with collagen (PL-chip) were used to assess PTF at high-shear in whole blood. The times to increase by 10 and 30 kPa (T10 and T30) from baseline were calculated and compared with those of the pediatric controls. Changes in the parameters during the treatment course and the relationship between pathological severity and the parameters were evaluated. RESULTS T10 and T30 parameters in the PL-chip were significantly shorter, and the area under the curves were greater in the case group than those in the control group (both p < 0.05). Each parameter was enhanced during the 3-week treatment but improved after the end of treatment. No significant relationship was observed between pathological severity and these parameters. Little PTF difference was observed between IgAN and Henoch-Schönlein purpura nephritis. CONCLUSIONS Pediatric MesPGN increased the potential for PTF under high-shear flow conditions.
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Affiliation(s)
- Takashi Omae
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
- Department of Community-Based Medicine, Nara Medical University, Kashihara, Japan
| | - Tomoaki Ishikawa
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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Czerwińska-Jelonkiewicz K, Sanetra K, Buszman PP, Gryszko L, Wood A, Crescenzi O, Milewski K, Buszman PE. Hemostatic disorders in patients with infective endocarditis undergoing urgent surgical valve replacement - Rethinking current beliefs. Int J Cardiol 2023; 388:131112. [PMID: 37343789 DOI: 10.1016/j.ijcard.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/19/2023] [Accepted: 06/02/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Although infective endocarditis (IE) represents a unique model of thrombo-inflammatory disease, the most frequent early complications of surgical valve replacement (SVR) in IE population are coagulopathy and bleeding. The hemostatic capacity and procedure-related coagulation disorders of IE patients undergoing SVR are unknown. The aims of this study were to test periprocedural hemostasis in IE patients undergoing urgent SVR, and to assess the association between disorders of hemostasis and early bleeding as well as with thromboembolic events. METHODS A prospective, two-center, hypothesis generating, observational study was performed between Dec 2017 and Jan 2020. Periprocedural hemostasis of IE patients was assessed using Total Thrombus-formation Analysis System (T-TAS Plus) within 24 h before and 72 h post SVR. RESULTS Overall, 25 patients with active IE undergoing urgent SVR were tested. Hemostatic capacity of IE patients was significantly impaired pre-SVR as well as post-SVR compared to normal values, in most aspects of T-TAS assays under high and low shear forces, including prolonged activation of coagulation (T10), final clot formation (OT) and clot strength (AUC30). Post-SVR T-TAS results were significantly associated with early bleeding and with red blood cell, platelet, and fresh frozen plasma administration. No association with thrombo-embolic events was found. CONCLUSIONS Patients with active IE undergoing urgent SVR have significantly reduced hemostatic capacity before and after SVR. Hemostatic insufficiency post-SVR is related to bleeding and blood products transfusion. T-TAS may be helpful in assessment of periprocedural hemostasis in patients with IE undergoing SVR.
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Affiliation(s)
- Katarzyna Czerwińska-Jelonkiewicz
- Division of Cardiology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland; Adults Intensive Care Unit, Royal Brompton and Harefiled Hospitals, NHS Foundation Trust, London, United Kingdom.
| | - Krzysztof Sanetra
- Division of Cardiology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland; Department of Cardiac Surgery, American Heart of Poland Inc., Bielsko-Biała, Poland
| | - Piotr P Buszman
- Division of Cardiology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland; Center for Cardiovascular Research and Development, American Heart of Poland Inc., Poland
| | - Leszek Gryszko
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Alice Wood
- Cardiology Department, Glenfield Hospital, Leicester, United Kingdom
| | - Oliviero Crescenzi
- Department of Anaesthesia and Critical Care, Royal Brompton and Harefiled Hospitals, NHS Foundation Trust, London, United Kingdom
| | - Krzysztof Milewski
- Center for Cardiovascular Research and Development, American Heart of Poland Inc., Poland
| | - Paweł E Buszman
- Medical University of Silesia, Epidemiology Department, Katowice, Poland
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Jamiolkowski MA, Golding MD, Malinauskas RA, Lu Q. In Vitro Thrombogenicity Testing of Biomaterials in a Dynamic Flow Loop: Effects of Length and Quantity of Test Samples. J Med Device 2023; 17:031003. [PMID: 37554290 PMCID: PMC10405281 DOI: 10.1115/1.4062863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/16/2023] [Indexed: 08/10/2023] Open
Abstract
The results of in vitro dynamic thrombogenicity testing of biomaterials and medical devices can be significantly impacted by test conditions. To develop and standardize a robust dynamic in vitro thrombogenicity tool, the key test parameters need to be appropriately evaluated and optimized. We used a flow loop test system previously developed in our laboratory to investigate the effects of sample length and the number of samples per test loop on the thrombogenicity results. Porcine blood heparinized to a donor-specific target concentration was recirculated at room temperature through polyvinyl chloride (PVC) tubing loops containing test materials for 1 h at 200 mL/min. Four test materials (polytetrafluoroethylene (PTFE), latex, PVC, and silicone) with various thrombotic potentials in two sample lengths (12 and 18 cm) were examined. For the 12-cm long materials, two different test configurations (one and two samples per loop) were compared. Thrombogenicity was assessed through percent thrombus surface coverage, thrombus weight, and platelet count reduction in the blood. The test system was able to effectively differentiate the thrombogenicity profile of the materials (latex > silicone > PVC ≥ PTFE) at all test configurations. Increasing test sample length by 50% did not significantly impact the test results as both 12 and 18 cm sample lengths were shown to equally differentiate thrombotic potentials between the materials. The addition of a second test sample to each loop did not increase the test sensitivity and may produce confounding results, and thus a single test sample per loop is recommended.
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Affiliation(s)
| | | | | | - Qijin Lu
- U.S. Food and Drug Administration, Silver Spring, MD 20993
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Schoerghuber M, Bärnthaler T, Prüller F, Mantaj P, Cvirn G, Toller W, Klivinyi C, Mahla E, Heinemann A. Supplemental fibrinogen restores thrombus formation in cardiopulmonary bypass-induced platelet dysfunction ex vivo. Br J Anaesth 2023; 131:452-462. [PMID: 37087333 PMCID: PMC10485366 DOI: 10.1016/j.bja.2023.03.010] [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: 09/04/2022] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Major cardiac surgery related blood loss is associated with increased postoperative morbidity and mortality. Platelet dysfunction is believed to contribute to post-cardiopulmonary bypass (CPB)-induced microvascular bleeding. We hypothesised that moderately hypothermic CPB induces platelet dysfunction and that supplemental fibrinogen can restore in vitro thrombus formation. METHODS Blood from 18 patients, undergoing first-time elective isolated aortic valve surgery was drawn before CPB, 30 min after initiation of CPB, and after CPB and protamine administration, respectively. Platelet aggregation was quantified by optical aggregometry, platelet activation by flow-cytometric detection of platelet surface expression of P-selectin, annexin V, and activated glycoprotein IIb/IIIa, thrombus formation under flow and effect of supplemental fibrinogen (4 mg ml-1) on in vitro thrombogenesis. RESULTS Post-CPB adenosine-diphosphate and TRAP-6-induced aggregation decreased by 40% and 10% of pre-CPB levels, respectively (P<0.0001). Although CPB did not change glycoprotein IIb/IIIa receptor expression, it increased the percentage of unstimulated P-selectin (1.2% vs 7%, P<0.01) positive cells and annexin V mean fluorescence intensity (15.5 vs 17.2, P<0.05), but decreased percentage of stimulated P-selectin (52% vs 26%, P<0.01) positive cells and annexin V mean fluorescence intensity (508 vs 325, P<0.05). Thrombus area decreased from 6820 before CPB to 5230 after CPB (P<0.05, arbitrary units [a.u.]). Supplemental fibrinogen increased thrombus formation to 20 324 and 11 367 a.u. before CPB and after CPB, respectively (P<0.001), thereby restoring post-CPB thrombus area to levels comparable with or higher than pre-CPB baseline. CONCLUSIONS Single valve surgery using moderately hypothermic CPB induces partial platelet dysfunction. Thrombus formation was restored in an experimental study design by ex vivo supplementation of fibrinogen.
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Affiliation(s)
- Michael Schoerghuber
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Bärnthaler
- 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
| | - Polina Mantaj
- Department of Cardiac Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Cvirn
- Otto Loewi Research Center, Division of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Christoph Klivinyi
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Mahla
- Department of Anesthesiology and Intensive Care 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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Yoshii R, Sawa T, Kawajiri H, Amaya F, Tanaka KA, Ogawa S. A comparison of the ClotPro system with rotational thromboelastometry in cardiac surgery: a prospective observational study. Sci Rep 2022; 12:17269. [PMID: 36241854 PMCID: PMC9568545 DOI: 10.1038/s41598-022-22119-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 10/10/2022] [Indexed: 01/06/2023] Open
Abstract
Viscoelastic coagulation tests have been increasingly used for hemostasis management in cardiac surgery. The ClotPro system is a novel viscoelastic device based on principles of rotational thromboelastometry. We aimed to compare ClotPro with ROTEM and plasma coagulation assays in cardiopulmonary bypass (CPB) patients. Blood samples were collected from 25 CPB patients at (1) baseline, (2) start of CPB, (3) end of CPB, and (4) end of surgery. The EX-test, IN-test, HI-test, FIB-test parameters on ClotPro were compared with corresponding ROTEM assay (EXTEM, INTEM, HEPTEM, and FIBTEM). Standard plasma coagulation assays and endogenous thrombin generation (TG) were simultaneously evaluated. Pearson correlation analyses showed moderate correlations between clotting times (CTs) (r = 0.63-0.67; p < 0.001, respectively), and strong correlations with maximal clot firmness (MCF) (r = 0.93-0.98; p < 0.001, respectively) between ClotPro and ROTEM. EX-test and IN-test MCF parameters were interchangeable with acceptable percentage errors (EX-test MCF: 7.3%, IN-test MCF: 8.3%), but FIB-test MCF (27.0%) and CT results were not (EX-test CT: 44.7%, IN-test CT: 31.4%). The correlations of PT/INR or peak TG with EX-test CTs were higher than with EXTEM CTs (PT/INR: r = 0.80 and 0.41, peak TG: 0.43 and 0.18, respectively). FIB-test MCF has strong correlation with plasma fibrinogen and factor XIII level (r = 0.84 and 0.66, respectively). ROC analyses showed that ClotPro was capable of emulating well-established ROTEM thresholds (area under curves: 0.83-1.00). ClotPro demonstrated strong correlations in MCF parameters of ROTEM in CPB patients. It may be reasonable to modify ROTEM-based transfusion algorithm pertaining to MCF parameters to establish cut-off values for ClotPro device.
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Affiliation(s)
- Ryogo Yoshii
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiji Sawa
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hidetake Kawajiri
- grid.272458.e0000 0001 0667 4960Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | - Fumimasa Amaya
- grid.272458.e0000 0001 0667 4960Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566 Japan
| | - Kenichi A. Tanaka
- grid.266902.90000 0001 2179 3618Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma, USA
| | - Satoru Ogawa
- grid.272458.e0000 0001 0667 4960Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan ,grid.272458.e0000 0001 0667 4960Department of Pain Management and Palliative Care Medicine, Kyoto Prefectural University of Medicine, Kawaramachi Hirokoji, Kamigyo, Kyoto, 602-8566 Japan
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Jamiolkowski MA, Patel M, Golding MD, Malinauskas RA, Lu Q. Comparison of Animal and Human Blood for In Vitro Dynamic Thrombogenicity Testing of Biomaterials. Artif Organs 2022; 46:2400-2411. [PMID: 35866431 PMCID: PMC9669094 DOI: 10.1111/aor.14366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/16/2022] [Accepted: 07/11/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND To determine suitable alternatives to human blood for in vitro dynamic thrombogenicity testing of biomaterials, four different animal blood sources (ovine, bovine, and porcine blood from live donors, and abattoir porcine blood) were compared to fresh human blood. METHODS To account for blood coagulability differences between individual donors and species, each blood pool was heparinized to a donor-specific concentration immediately before testing in a dynamic flow loop system. The target heparin level was established using a static thrombosis pre-test. For dynamic testing, whole blood was recirculated at room temperature for 1 hr at 200 mL/min through a flow loop containing a single test material. Four materials with varying thrombotic potentials were investigated: latex (positive control), polytetrafluoroethylene (PTFE) (negative control), silicone (intermediate thrombotic potential), and high-density polyethylene (HDPE) (historically thromboresistant). Thrombus weight and surface area coverage on the test materials were quantified, along with platelet count reduction in the blood. RESULTS While donor-specific heparin levels varied substantially from 0.6 U/ml to 7.0 U/mL among the different blood sources, each source was able to differentiate between the thrombogenic latex and the thromboresistant PTFE and HDPE materials (P< 0.05). However, only donor ovine and bovine blood were sensitive enough to differentiate an increased response for the intermediate thrombotic silicone material compared to PTFE and HDPE. CONCLUSIONS These results demonstrated that multiple animal blood sources (particularly donor ovine and bovine blood) may be suitable alternatives to fresh human blood for dynamic thrombogenicity testing when appropriate control materials and donor-specific anticoagulation levels are used.
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Affiliation(s)
- Megan A Jamiolkowski
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Mehulkumar Patel
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Madelyn D Golding
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Richard A Malinauskas
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Qijin Lu
- Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
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9
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Kim JS, Ellis WC, Ing RJ. Does the Volume and Constitution of Cardiopulmonary Bypass Priming Fluids Affect Blood Loss After Cardiac Surgery in Children? J Cardiothorac Vasc Anesth 2022; 36:1595-1597. [PMID: 35148942 DOI: 10.1053/j.jvca.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/11/2022]
Affiliation(s)
- John S Kim
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO
| | - W Cory Ellis
- Perfusion, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO
| | - Richard J Ing
- Department of Anesthesiology, Heart Institute, Children's Hospital Colorado, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora, CO.
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10
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Sikora J, Karczmarska-Wódzka A, Bugieda J, Sobczak P. The Use of Total Thrombus Formation Analysis System as a Tool to Assess Platelet Function in Bleeding and Thrombosis Risk-A Systematic Review. Int J Mol Sci 2021; 22:8605. [PMID: 34445311 PMCID: PMC8395324 DOI: 10.3390/ijms22168605] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Today there are many devices that can be used to study blood clotting disorders by identifying abnormalities in blood platelets. The Total Thrombus Formation Analysis System is an automated microchip flow chamber system that is used for the quantitative analysis of clot formation under blood flow conditions. For several years, researchers have been using a tool to analyse various clinical situations of patients to identify the properties and biochemical processes occurring within platelets and their microenvironment. METHODS An investigation of recent published literature was conducted based on PRISMA. This review includes 52 science papers directly related to the use of the Total Clot Formation Analysis System in relation to bleeding, surgery, platelet function assessment, anticoagulation monitoring, von Willebrand factor and others. CONCLUSION Most available studies indicate that The Total Thrombus Formation Analysis System may be useful in diagnostic issues, with devices used to monitor therapy or as a significant tool for predicting bleeding events. However, T-TAS not that has the potential for diagnostic indications, but allows the direct observation of the flow and the interactions between blood cells, including the intensity and dynamics of clot formation. The device is expected to be of significant value for basic research to observe the interactions and changes within platelets and their microenvironment.
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Affiliation(s)
- Joanna Sikora
- Research and Education Unit for Experimental Biotechnology, Department of Transplantology and General Surgery, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (A.K.-W.); (J.B.)
| | - Aleksandra Karczmarska-Wódzka
- Research and Education Unit for Experimental Biotechnology, Department of Transplantology and General Surgery, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (A.K.-W.); (J.B.)
| | - Joanna Bugieda
- Research and Education Unit for Experimental Biotechnology, Department of Transplantology and General Surgery, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (A.K.-W.); (J.B.)
| | - Przemysław Sobczak
- Department of Hematology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland;
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11
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Colomina MJ, Méndez E, Sabate A. Altered Fibrinolysis during and after Surgery. Semin Thromb Hemost 2021; 47:512-519. [PMID: 33878781 DOI: 10.1055/s-0041-1722971] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Major surgery induces hemostatic changes related to surgical stress, tissue destruction, and inflammatory reactions. These changes involve a shift of volume from extravascular space to intravascular and interstitial spaces, a "physiologic" hemodilution of coagulation proteins, and an increase of plasmatic fibrinogen concentration and platelets. Increases in fibrinogen and platelets together with a simultaneous dilution of pro- and anticoagulant factors and development of a hypofibrinolytic status result in a postoperative hypercoagulable state. This profile is accentuated in more extensive surgery, but the balance can shift toward hemorrhagic tendency in specific types of surgeries, for example, in prolonged cardiopulmonary bypass or in patients with comorbidities, especially liver diseases, sepsis, and hematological disorders. Also, acquired coagulopathy can develop in patients with trauma, during obstetric complications, and during major surgery as a result of excessive blood loss and subsequent consumption of coagulation factors as well as hemodilution. In addition, an increasing number of patients receive anticoagulants and antiplatelet drugs preoperatively that might influence the response to surgical hemostasis. This review focuses on those situations that may change normal hemostasis and coagulation during surgery, producing both hyperfibrinolysis and hypofibrinolysis, such as overcorrection with coagulation factors, bleeding and hyperfibrinolysis that may occur with extracorporeal circulation and high aortic-portal-vena cava clamps, and hyperfibrinolysis related to severe maintained hemodynamic disturbances. We also evaluate the role of tranexamic acid for prophylaxis and treatment in different surgical settings, and finally the value of point-of-care testing in the operating room is commented with regard to investigation of fibrinolysis.
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Affiliation(s)
- Maria J Colomina
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain.,Universidad de Barcelona, Barcelona, Spain
| | - Esther Méndez
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain
| | - Antoni Sabate
- Department of Anaesthesia and Critical Care, Bellvitge University Hospital, L'Hospitalet de LLobregat, Barcelona, Spain.,Universidad de Barcelona, Barcelona, Spain
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12
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Boyd CJ, Brainard BM, Smart L. Intravenous Fluid Administration and the Coagulation System. Front Vet Sci 2021; 8:662504. [PMID: 33937383 PMCID: PMC8081828 DOI: 10.3389/fvets.2021.662504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/15/2021] [Indexed: 12/30/2022] Open
Abstract
Intravenous fluid administration in veterinary patients can alter coagulation function by several mechanisms. Both crystalloid and colloid fluids cause hemodilution, reducing platelet count and plasma coagulation protein concentrations. Hemodilution is associated with a hypercoagulable effect at low dilutions and a hypocoagulable effect at higher dilutions. Composition of crystalloid fluids likely has a minor effect, primarily dependent on fluid ion composition. Hypertonic crystalloids may also cause hypocoagulability. Colloids, both synthetic and natural, can cause hypocoagulability by several mechanisms beyond the effects of hemodilution. These include impaired platelet function, decreased plasma coagulation factor activity, impaired fibrin formation and crosslinking, and accelerated fibrinolysis. The vast majority of the veterinary literature investigates the hypocoagulable effects of hydroxyethyl starch-containing fluids using in vitro, experimental, and clinical studies. However, results are inconsistent, likely due to the varying doses and physicochemical properties of the specific fluid products across studies. In addition, some evidence exists for hypocoagulable effects of gelatin and albumin solutions. There is also evidence that these colloids increase the risk of clinical bleeding in people. Limitations of the veterinary evidence for the hypocoagulable effects of colloid fluids include a predominance of in vitro studies and in vivo studies using healthy subjects, which exclude the interaction of the effects of illness. Therefore, clinical relevance of these effects, especially for low-molecular-weight hydroxyethyl starch, is unknown. Firm recommendations about the most appropriate fluid to use in clinical scenarios cannot be made, although it is prudent to limit the dose of synthetic colloid in at-risk patients. Clinicians should closely monitor relevant coagulation assays and for evidence of hemorrhage in at-risk patients receiving any type of fluid therapy, especially in large volumes.
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Affiliation(s)
- Corrin J Boyd
- School of Veterinary Medicine, College of Science, Health, Engineering and Education, Murdoch University, Murdoch, WA, Australia
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Lisa Smart
- School of Veterinary Medicine, College of Science, Health, Engineering and Education, Murdoch University, Murdoch, WA, Australia
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13
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Henderson RA, Judd M, Strauss ER, Gammie JS, Mazzeffi MA, Taylor BS, Tanaka KA. Hematologic evaluation of intraoperative autologous blood collection and allogeneic transfusion in cardiac surgery. Transfusion 2021; 61:788-798. [DOI: 10.1111/trf.16259] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 11/27/2020] [Accepted: 11/28/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Reney A. Henderson
- Division of Cardiovascular Anesthesia, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - Miranda Judd
- Division of Cardiovascular Anesthesia, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - Erik R. Strauss
- Division of Cardiovascular Anesthesia, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - James S. Gammie
- Division of Cardiac Surgery, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - Michael A. Mazzeffi
- Division of Cardiovascular Anesthesia, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - Bradley S. Taylor
- Division of Cardiac Surgery, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - Kenichi A. Tanaka
- Division of Cardiovascular Anesthesia, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
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14
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Tsantes AG, Trikoupis IG, Papadopoulos DV, Tsante KA, Mavrogenis AF, Koulouvaris P, Savvidou OD, Kontogeorgakos VA, Piovani D, Kriebardis AG, Bonovas S, Papagelopoulos PJ, Tsantes AE. Higher coagulation activity in hip fracture patients: A case-control study using rotational thromboelastometry. Int J Lab Hematol 2020; 43:477-484. [PMID: 33231378 DOI: 10.1111/ijlh.13409] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/02/2020] [Accepted: 11/07/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Trauma-induced coagulopathy has been extensively investigated in the multitrauma setting, but only sparsely following moderate orthopedic trauma. The purpose of this study was to evaluate changes in the hemostatic profile of patients with hip fractures, using rotational thromboelastometry (ROTEM). METHODS 198 patients with hip fractures who underwent surgery were included in the study. A matched group of 52 healthy individuals was also enrolled. Demographics, conventional laboratory assays, and ROTEM parameters were recorded and compared between patients and healthy adults. The preoperative and postoperative ROTEM values of fractured patients were also compared. RESULTS The conventional coagulation assays were similar for the 2 groups. However, several ROTEM parameters including EXTEM MCF (P < .001), EXTEM alpha angle (P < .001), INTEM MCF (P < .001), INTEM A10 (P < .001), and INTEM alpha angle (P < .001) significantly differed between the 2 groups indicating a higher coagulation potential following hip fractures. Also, fractured patients had significantly lower INTEM and EXTEM CT values (P = .008 and P = .012, respectively) and significantly lower INTEM and EXTEM CFT values (P < .001). Adjusted analysis for confounders further confirmed the direct relationship between hip fracture and higher coagulation activity. Last, INTEM CT and CFT significantly decreased (P = .008 and P < .001, respectively), while INTEM MCF, A10, and alpha angle significantly increased (P < .001) postoperatively, indicating that surgery further increases the coagulation potential. CONCLUSION A higher coagulation activity following hip fractures and surgical treatment can be detected by ROTEM shortly after the injury, even when this is undetectable by conventional coagulation assays.
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Affiliation(s)
- Andreas G Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis G Trikoupis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitrios V Papadopoulos
- Department of Orthopaedic Surgery, University of Pittsburgh, Orthopedic Specialists-UPMC, Pittsburgh, PA, USA
| | - Konstantina A Tsante
- Laboratory of Reliability and Quality Control in Laboratory Hematology (HemQcR), Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica (UniWA), Egaleo, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panagiotis Koulouvaris
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Olga D Savvidou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vasilios A Kontogeorgakos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Humanitas Clinical and Research Center- IRCCS, Milan, Italy
| | - Anastasios G Kriebardis
- Laboratory of Reliability and Quality Control in Laboratory Hematology (HemQcR), Department of Biomedical Sciences, School of Health & Caring Sciences, University of West Attica (UniWA), Egaleo, Greece
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Humanitas Clinical and Research Center- IRCCS, Milan, Italy
| | - Panayiotis J Papagelopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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15
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Tsujii N, Nogami K, Yoshizawa H, Sakai T, Fukuda K, Ishiguro A, Shima M. Assessment of Platelet Thrombus Formation under Flow Conditions in Patients with Acute Kawasaki Disease. J Pediatr 2020; 226:266-273. [PMID: 32553864 DOI: 10.1016/j.jpeds.2020.06.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To assess platelet thrombus formation (PTF) under flow conditions in patients with Kawasaki disease. Previously available platelet activation data were limited for nonphysiological shear stress condition. The total thrombus-formation analysis system (T-TAS) was developed for quantitative PTF analysis. STUDY DESIGN In total, 33 patients with acute Kawasaki disease were assessed. Whole blood samples, obtained immediately before treatment and 1 week and 1 month after treatment, were assessed using the T-TAS with a collagen-coated platelet chip under high shear values (1000 s-1 [PL12] and 2000 s-1 [PL24]). Measures, such as time to reach 5 kPa above the base pressure (T5+α) and area under the curve for flow pressure curve for 10 minutes (AUC10) were analyzed to quantify PTF. RESULTS Immediately before treatment, the median PL12-T5+α and PL24-T5+α were 3.3 minutes (IQR 2.0-4.5) and 1.3 minutes (0.9-1.9), respectively, and both values were significantly lower in adult controls (3.5 minutes [2.9-6.4] and 2.8 minutes [1.8-4.8]; P = .015 and P < .001, respectively). In addition, the PL12-AUC10 (151.7 U [94.5-279.9]) significantly decreased in adult controls (234.1 U [110.5-306.5], P = .007). By contrast, at 1 week and 1 month after the start of treatment, the T5+α was longer, and the PL12-AUC10 and PL24-AUC10 decreased. CONCLUSIONS In patients with acute Kawasaki disease, the PTF had an early onset and weak stability.
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Affiliation(s)
- Nobuyuki Tsujii
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.
| | - Hiroyuki Yoshizawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Toshiyuki Sakai
- Department of Pediatrics, Kokuho Central Hospital, Shiki, Nara, Japan
| | - Kazuyoshi Fukuda
- Department of Pediatrics, Saiseikai Chuwa Hospital, Sakurai, Nara, Japan
| | - Akira Ishiguro
- Department of Postgraduate Education and Training, National Center for Child Health and Development, Tokyo, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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16
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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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17
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Yamazaki M. Monitoring of Antithrombotic Therapy. J Atheroscler Thromb 2020; 27:201-203. [PMID: 31685715 PMCID: PMC7113145 DOI: 10.5551/jat.ed120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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18
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An In Vitro Blood Flow Loop System for Evaluating the Thrombogenicity of Medical Devices and Biomaterials. ASAIO J 2020; 66:183-189. [PMID: 30807378 PMCID: PMC10370649 DOI: 10.1097/mat.0000000000000958] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A reliable in vitro dynamic test method to evaluate device thrombogenicity is very important for the improvement of the design and safety of blood-contacting medical devices, while reducing the use of animal studies. In this study, a recirculating flow loop system was developed for thrombogenicity testing, using donor sheep blood anticoagulated with Anticoagulant Citrate Dextrose Solution A (ACDA) and used within 24-36 hr postdraw. Immediately before testing, the blood was recalcified and heparinized to a donor-specific target concentration. The heparinization level was based on a static pretest, in which latex tubes were incubated at room temperature for 30 min in blood with a series of heparin concentrations and evaluated for thrombus deposition. For dynamic testing, blood was recirculated at room temperature through a polyvinyl chloride (PVC) tubing loop containing a test material for 1 hr at 200 ml/min using a roller pump. Nine materials were investigated: a negative control (polytetrafluoroethylene [PTFE]), a positive control (latex), and seven commonly used biomaterials including PVC, two silicones with different formulations (Q-Sil and V-Sil), nylon, polyurethane (PU), high-density polyethylene (HDPE), and polyether block amide (PEBAX). The results showed that latex was significantly more thrombogenic than all the other materials (p < 0.05), PVC and Q-Sil exhibited intermediate thrombogenicity with significantly more thrombus surface coverage and thrombus weight than PTFE (p < 0.05), whereas PTFE and the rest of the biomaterials had little to no thrombus deposition. In summary, the test loop system was able to effectively differentiate materials with different thrombogenic potentials.
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19
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Guarnieri M, De Gasperi A, Gianni S, Baciarello M, Bellini V, Bignami E. From the Physiology to the Bedside: Fluid Therapy in Cardiac Surgery and the ICU. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00341-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Szydzik C, Brazilek RJ, Akbaridoust F, de Silva C, Moon M, Marusic I, Ooi ASH, Nandurkar HH, Hamilton JR, Mitchell A, Nesbitt WS. Active Micropump-Mixer for Rapid Antiplatelet Drug Screening in Whole Blood. Anal Chem 2019; 91:10830-10839. [PMID: 31343155 DOI: 10.1021/acs.analchem.9b02486] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
There is a need for scalable automated lab-on-chip systems incorporating precise hemodynamic control that can be applied to high-content screening of new more efficacious antiplatelet therapies. This paper reports on the development and characterization of a novel active micropump-mixer microfluidic to address this need. Using a novel reciprocating elastomeric micropump design, we take advantage of the flexible structural and actuation properties of this framework to manage the hemodynamics for on-chip platelet thrombosis assay on type 1 fibrillar collagen, using whole blood. By characterizing and harnessing the complex three-dimensional hemodynamics of the micropump operation in conjunction with a microvalve controlled reagent injection system we demonstrate that this prototype can act as a real-time assay of antiplatelet drug pharmacokinetics. In a proof-of-concept preclinical application, we utilize this system to investigate the way in which rapid dosing of human whole blood with isoform selective inhibitors of phosphatidylinositol 3-kinase dose dependently modulate platelet thrombus dynamics. This modular system exhibits utility as an automated multiplexable assay system with applications to high-content chemical library screening of new antiplatelet therapies.
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Affiliation(s)
- Crispin Szydzik
- The Australian Centre for Blood Diseases , Monash University , 99 Commercial Road , Melbourne , Victoria 3004 , Australia.,School of Engineering , RMIT University , 124 La Trobe Street , Melbourne , Victoria 3000 , Australia
| | - Rose J Brazilek
- The Australian Centre for Blood Diseases , Monash University , 99 Commercial Road , Melbourne , Victoria 3004 , Australia
| | - Farzan Akbaridoust
- School of Engineering , RMIT University , 124 La Trobe Street , Melbourne , Victoria 3000 , Australia.,Department of Mechanical Engineering, Melbourne School of Engineering , The University of Melbourne , Melbourne , Victoria 3010 , Australia
| | - Charitha de Silva
- Department of Mechanical Engineering, Melbourne School of Engineering , The University of Melbourne , Melbourne , Victoria 3010 , Australia.,School of Mechanical and Manufacturing Engineering , The University of New South Wales , Sydney , New South Wales 2052 , Australia
| | - Mitchell Moon
- The Australian Centre for Blood Diseases , Monash University , 99 Commercial Road , Melbourne , Victoria 3004 , Australia
| | - Ivan Marusic
- Department of Mechanical Engineering, Melbourne School of Engineering , The University of Melbourne , Melbourne , Victoria 3010 , Australia
| | - Andrew S H Ooi
- Department of Mechanical Engineering, Melbourne School of Engineering , The University of Melbourne , Melbourne , Victoria 3010 , Australia
| | - Harshal H Nandurkar
- The Australian Centre for Blood Diseases , Monash University , 99 Commercial Road , Melbourne , Victoria 3004 , Australia
| | - Justin R Hamilton
- The Australian Centre for Blood Diseases , Monash University , 99 Commercial Road , Melbourne , Victoria 3004 , Australia
| | - Arnan Mitchell
- School of Engineering , RMIT University , 124 La Trobe Street , Melbourne , Victoria 3000 , Australia
| | - Warwick S Nesbitt
- The Australian Centre for Blood Diseases , Monash University , 99 Commercial Road , Melbourne , Victoria 3004 , Australia.,School of Engineering , RMIT University , 124 La Trobe Street , Melbourne , Victoria 3000 , Australia
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Rogalski P, Rogalska-Plonska M, Wroblewski E, Kostecka-Roslen I, Dabrowska M, Swidnicka-Siergiejko A, Wasielica-Berger J, Cydzik M, Hirnle T, Dobrzycki S, Flisiak R, Dabrowski A. Blood platelet function abnormalities in cirrhotic patients with esophageal varices in relation to the variceal bleeding history. Scand J Gastroenterol 2019; 54:311-318. [PMID: 30907172 DOI: 10.1080/00365521.2019.1578822] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objective: The study aimed at assessing the effect of thrombocytopenia and platelet function abnormalities on the occurrence of variceal bleeding in patients with cirrhosis. Methods: The results of impedance aggregometry, von Willebrand factor antigen level and thromboelastometry (TEM) with and without the addition of a platelet inhibitor (FIBTEM®, EXTEM® test, respectively) were compared in two patient groups: Group 1 (n = 32) - patients with moderate or large esophageal or gastric varices, who had never had symptoms of acute gastrointestinal bleeding and Group 2 (n = 26) - patients with history of variceal bleeding. Results: Standard clotting test indicated more hypocoagulable profile in Group 2 compared to Group 1. However, no differences in any TEM component were observed between groups in EXTEM® test. The contribution of platelets to clot strength was significantly higher in Group 2 than in Group 1 [PLT% = 74.2 (67.5-80.4) versus 68.8 (63.7-76.5) %; p = .039]. The aggregation index was also higher in Group 2 compared to Group 1, although not statistically significant [% of healthy = 96.9 (73.2-140.1) versus 67.6 (52.5-118.8) %, p = .195]. No differences in vWF antigen levels were observed between groups. Conclusions: The results of thromboelastometry and aggregometry indicate increased contribution of platelets in clot formation in patients with a history of variceal bleeding compared to cirrhotic patients who never bled. Comparable effectiveness of hemostasis in both groups is most likely associated with the compensatory role of platelets. Increased platelet activity in this group of patients is probably due to a mechanism independent of the von Willebrand factor antigen level.
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Affiliation(s)
- Pawel Rogalski
- a Department of Gastroenterology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
| | - Magdalena Rogalska-Plonska
- b Department of Infectious Diseases and Hepatology , Medical University of Bialystok , Bialystok , Poland
| | - Eugeniusz Wroblewski
- a Department of Gastroenterology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
| | - Ines Kostecka-Roslen
- c Department of Haematological Diagnostics , Medical University of Bialystok , Bialystok , Poland
| | - Milena Dabrowska
- c Department of Haematological Diagnostics , Medical University of Bialystok , Bialystok , Poland
| | | | - Justyna Wasielica-Berger
- a Department of Gastroenterology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
| | - Mariusz Cydzik
- d Department of Cardiosurgery , Medical University of Bialystok , Bialystok , Poland
| | - Tomasz Hirnle
- d Department of Cardiosurgery , Medical University of Bialystok , Bialystok , Poland
| | - Slawomir Dobrzycki
- e Department of Invasive Cardiology , Medical University of Bialystok , Bialystok , Poland
| | - Robert Flisiak
- b Department of Infectious Diseases and Hepatology , Medical University of Bialystok , Bialystok , Poland
| | - Andrzej Dabrowski
- a Department of Gastroenterology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
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22
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Cushing MM, Asmis LM, Harris RM, DeSimone RA, Hill S, Ivascu N, Haas T. Efficacy of a new pathogen-reduced cryoprecipitate stored 5 days after thawing to correct dilutional coagulopathy in vitro. Transfusion 2019; 59:1818-1826. [PMID: 30719724 DOI: 10.1111/trf.15157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 12/27/2018] [Accepted: 12/29/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Fibrinogen supplementation during bleeding restores clot strength and hemostasis. Cryoprecipitate, a concentrated source of fibrinogen, has prolonged preparation time for thawing, a short shelf life resulting in frequent wastage, and infectious disease risk. This in vitro study investigated the efficacy of a new pathogen-reduced cryoprecipitate thawed and stored at room temperature for 5 days (PR Cryo) to treat dilutional hypofibrinogenemia, compared to immediately thawed standard cryoprecipitate (Cryo) or fibrinogen concentrate (FC). STUDY DESIGN AND METHODS Ten phlebotomy specimens from healthy volunteers were diluted 1:1 with crystalloid and supplemented with PR Cryo and Cryo (at a dose replicating transfusion of two pooled doses [10 units]) and FC at a dose replicating 50 mg/kg. Changes in clot firmness (thromboelastometry) and in coagulation factor activity were assessed at baseline, after dilution, and after supplementation. RESULTS Clinical dosing was used, as described above, and consequently the FC dose contained 24% and 36% more fibrinogen versus PR Cryo and Cryo, respectively. At baseline, subjects had a median FIBTEM maximum clot firmness of 13.5 mm, versus 6.5 mm after 50% dilution (p = 0.005). After supplementation with PR Cryo, a median FIBTEM maximum clot firmness of 13 mm was observed versus 9.0 mm for Cryo (p = 0.005) or 16.5 mm for FC (p = 0.005). Median factor XIII was higher after PR Cryo (64.8%) versus Cryo (48.3%) (p = 0.005). Fibrinogen activity was higher after FC (269.0 mg/dL) versus PR Cryo (187.0 mg/dL; p = 0.005) or Cryo (193.5 mg/dL; p = 0.005); the difference between PR Cryo and Cryo supplementation (p = 0.445) was not significant. CONCLUSION PR Cryo used 5 days after thawing effectively restores clot strength after in vitro dilution.
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Affiliation(s)
- Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
| | - Rebecca M Harris
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Robert A DeSimone
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Shanna Hill
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Natalia Ivascu
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Thorsten Haas
- Department of Anaesthesia, Zurich University Children's Hospital, Zurich, Switzerland
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Takeshita S, Ogawa S, Nakayama Y, Mukai N, Nakajima Y, Mizobe T, Sawa T, Tanaka KA. Prohemostatic Activity of Factor X in Combination With Activated Factor VII in Dilutional Coagulopathy. Anesth Analg 2018; 129:339-345. [PMID: 30320649 DOI: 10.1213/ane.0000000000003858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa) concentrate reduces allogeneic blood transfusions, but it may increase thromboembolic complications in complex cardiac surgery. The mixture of activated factor VII (FVIIa) and factor X (FX) (FVIIa/FX) (FVIIa:FX = 1:10) is a novel bypassing agent for hemophilia patients. We hypothesized that the combination of FX and FVIIa could improve thrombin generation (TG) in acquired multifactorial coagulation defects such as seen in cardiac surgery and conducted in vitro evaluation of FVIIa/FX in parallel with other coagulation factor concentrates using in vitro and in vivo diluted plasma samples. METHODS Plasma samples were collected from 9 healthy volunteers and 12 cardiac surgical patients. We measured TG (Thrombinoscope) using in vitro 50% dilution plasma and in vivo dilution plasma after cardiopulmonary bypass, in parallel with thromboelastometry (ROTEM) and standard coagulation assays. In vitro additions of FVIIa/FX (0.35, 0.7, and 1.4 μg/mL, based on the FVIIa level), rFVIIa (1.4, 2.8, and 6.4 μg/mL), prothrombin complex concentrate (0.3 international unit), and 20% plasma replacement were evaluated. RESULTS In diluted plasma, the addition of either FVIIa/FX or rFVIIa shortened the lag time and increased the peak TG, but the effect in lag time of FVIIa/FX at 0.35 μg/mL was more extensive than rFVIIa at 6.4 μg/mL. Prothrombin complex concentrate increased peak TG by increasing the prothrombin level but failed to shorten the lag time. No improvement in any of the TG variables was observed after 20% volume replacement with plasma. The addition of factor concentrates normalized prothrombin time/international normalized ratio but not with plasma replacement. In cardiac patients, similar patterns were observed on TG in post-cardiopulmonary bypass samples. FVIIa/FX shortened clotting time (CT) in a concentration-dependent manner on CT on thromboelastometry. Plasma replacement did not improve CT, but a combination of plasma and FVIIa/FX (0.35 μg/mL) more effectively shortened CT than FVIIa/FX alone. CONCLUSIONS The combination of FVIIa and FX improved TG more efficiently than rFVIIa alone or plasma in dilutional coagulopathy models. The required FVIIa dose in FVIIa/FX was considerably lower than those reported during bypassing therapy in hemophilia patients (1.4-2.8 μg/mL). The combination of plasma could restore coagulation more efficiently compared to FVIIa/FX alone. Lesser FVIIa requirement to exert procoagulant activity may be favorable in terms of reducing systemic thromboembolic complications.
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Affiliation(s)
- Shusuke Takeshita
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoru Ogawa
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshinobu Nakayama
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuhiro Mukai
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasufumi Nakajima
- Department of Anesthesiology, Kansai Medical University, Osaka, Japan
| | - Toshiki Mizobe
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiji Sawa
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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Kam P, Varanasi S, Yang KX. The effects of haemodilution with succinylated gelatin solution on coagulation in vitro as assessed by thromboelastometry and impedance (multiple electrode) aggregometry. Anaesth Intensive Care 2018; 46:272-277. [PMID: 29716485 DOI: 10.1177/0310057x1804600304] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We investigated the in vitro viscoelastic changes of progressive haemodilution with succinylated gelatin (SG) solution compared with normal saline (NS) using rotational thromboelastometry (ROTEM®). Whole blood (WB) samples obtained from 20 healthy volunteers were diluted in vitro with SG solution or NS by 10%, 20% and 40%. Fibrinogen concentration and ROTEM (EXTEM, FIBTEM) variables including coagulation time (CT), clot formation time (CFT), α-angle, and maximum clot firmness (MCF) were measured in the undiluted sample and at each degree of haemodilution. Haemodilution with SG decreased FIBTEM MCF by 34.8% at 20% dilution (SG 20% haemodilution mean 9.1 [standard deviation, SD 2.7] mm versus WB, mean 13.9 [SD 3.4] mm) whereas this was observed only at 40% haemodilution with NS (mean 8.5 [SD 2.7] mm, 38.7% decrease). We found that 40% haemodilution with SG slowed clot formation (EXTEM CFT; SG 40%, mean 179 [SD 39] seconds versus WB mean 87.9 [SD 13.7] seconds; increased CFT by 103%), reduced clot strength by 23.5% (EXTEM MCF; SG 40% mean 47.7 [SD 3.4] mm versus WB mean 62.4 [SD 2.5] mm), and decreased fibrin formation (FIBTEM MCF; SG 40% mean 5.8 [SD 1.6] mm versus WB mean 13.9 [SD 3.4] mm); 58.4% decrease). The platelet contribution to clot strength (EXTEM MCF-FIBTEM MCF) was not changed by SG. We found that haemodilution of more than 20% with SG impaired coagulation greater than that observed with NS haemodilution in this in vitro study. This suggests that at 40% haemodilution with SG, a clinical scenario that could occur during resuscitation of a patient in grade IV haemorrhagic shock, impaired coagulation could occur. Frequent monitoring of coagulation is advised when SG solutions are administered rapidly during volume resuscitation.
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Affiliation(s)
- Pca Kam
- Nuffield Professor of Anaesthetics, University of Sydney; Anaesthetics Department, Royal Prince Alfred Hospital; Sydney, New South Wales
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Kam P, Liou J, Yang K. In vitro evaluation of the effect of haemodilution with dextran 40 on coagulation profile as measured by thromboelastometry and multiple electrode aggregometry. Anaesth Intensive Care 2017; 45:562-568. [PMID: 28911285 DOI: 10.1177/0310057x1704500506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We evaluated the effects of haemodilution with either dextran 40 or 0.9% normal saline on coagulation in vitro using rotational thromboelastometry (ROTEM®, Pentapharm Co., Munich, Germany) and multiple electrode aggregometry (Multiplate® Platelet Function Analyser, Dynabyte, Munich, Germany). Venous blood samples obtained from 20 healthy volunteers were diluted in vitro with dextran 40 or normal saline by 5%, 10% and 15%. Fibrinogen concentration, ROTEM-EXTEM® (screening test for the extrinsic coagulation pathway), FIBTEM® (an EXTEM-based assay of the fibrin component of clot) parameters including coagulation time, clot formation time, alpha angle, maximum clot firmness and lysis index were measured in the undiluted sample and at each level of haemodilution. Dextran 40 at 15% haemodilution significantly prolonged coagulation time, clot formation time and significantly decreased the alpha angle and maximal clot firmness (EXTEM amplitude at five minutes [A5] and ten minutes [A10]) compared with normal saline. The FIBTEM assay (maximal clot firmness and FIBTEM A5 and A10) showed a marked decrease in maximal clot firmness at all dilutions suggesting impaired fibrinogen activity and a risk of bleeding. Multiple electrode aggregometry did not demonstrate any platelet dysfunction. Haemodilution with dextran 40 causes significant impairment in clot formation and strength compared to saline haemodilution and undiluted blood. At the levels of in vitro haemodilution designed to reflect the clinical use of dextran infusions, no significant fibrinolysis or platelet inhibition was observed.
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Affiliation(s)
- Pca Kam
- Discipline of Anaesthetics , Sydney Medical School, University of Sydney
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26
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Jalaer I, Tsakiris D, Solecka-Witulska B, Kannicht C. The role of von Willebrand factor in primary haemostasis under conditions of haemodilution. Thromb Res 2017; 157:142-146. [DOI: 10.1016/j.thromres.2017.07.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/24/2017] [Accepted: 07/18/2017] [Indexed: 10/19/2022]
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Abuelkasem E, Hasan S, Mazzeffi MA, Planinsic RM, Sakai T, Tanaka KA. Reduced Requirement for Prothrombin Complex Concentrate for the Restoration of Thrombin Generation in Plasma From Liver Transplant Recipients. Anesth Analg 2017; 125:609-615. [DOI: 10.1213/ane.0000000000002106] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Peng Y, Du J, Zhao X, Shi X, Wang Y. Effects of colloid pre-loading on thromboelastography during elective intracranial tumor surgery in pediatric patients: hydroxyethyl starch 130/0.4 versus 5% human albumin. BMC Anesthesiol 2017; 17:62. [PMID: 28449710 PMCID: PMC5408379 DOI: 10.1186/s12871-017-0353-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 04/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Volume replacement therapy with colloid is still worth studying in major pediatric surgery with potential risk of bleeding. This study assessed the effects of 6% hydroxyethyl starch (HES) 130/0.4 and 5% Human Albumin (HA) on coagulation tested by thromboelastography (TEG) during elective intracranial tumor surgery in pediatric patients. METHODS In this randomized controlled trial, 60 patients undergoing intracranial tumor resection under general anesthesia were assigned to HES and HA groups (n = 30), and administered preloads of 20 mL · kg-1 HES 130/0.4 and 5% HA, respectively, prior to dura opening. Primary outcomes were perioperative thromboelastography findings, and hemodynamic and hematological parameters. Blood transfusion, perioperative fluid balance, intracranial pressure, mortality, intensive care unit stay, and hospital stay were also assessed. RESULTS TEG parameters did not differ after preloading compared to baseline values in either group, except for a decrease in maximum amplitude immediately after infusion (HES group, 57.6 ± 6.0 mm vs. 50.9 ± 9.2 mm; HA group, 60.1 ± 7.9 mm vs. 56.6 ± 7.1 mm; p < 0.01), which was restored to preoperative levels 1 h after fluid infusion. Total perioperative fluid balance, blood loss or transfusion, intracranial pressure, and hematological and hemodynamic variables were similar between both groups (p > 0.05). Mortality, length of hospital stay, and clinical complications were similar between both groups. CONCLUSION These findings suggest that HES and HA might have no significant differences regarding coagulation as assessed by TEG during pediatric intracranial tumor surgery with 20 ml/kg volume pre-loading, which can maintain stable hemodynamics and may represent a new avenue for volume therapy during brain tumor resection in pediatrics. TRIAL REGISTRATION ChiCTR-IPR- 16009333 , retrospectively registered October 8, 2016.
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Affiliation(s)
- Yuanzhi Peng
- Department of Anesthesiology, Xinhua Hospital Affiliated to Shanghai Jiao Tong, Shanghai, 200092, China
| | - Jianer Du
- Department of Anesthesiology, Xinhua Hospital Affiliated to Shanghai Jiao Tong, Shanghai, 200092, China
| | - Xuan Zhao
- Department of Anesthesiology, Xinhua Hospital Affiliated to Shanghai Jiao Tong, Shanghai, 200092, China
| | - Xueyin Shi
- Department of Anesthesiology, Xinhua Hospital Affiliated to Shanghai Jiao Tong, Shanghai, 200092, China.
| | - Yingwei Wang
- Department of Anesthesiology, Huashan Hospital, FuDan University, Shanghai, 200040, China.
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Nagy M, Heemskerk JWM, Swieringa F. Use of microfluidics to assess the platelet-based control of coagulation. Platelets 2017; 28:441-448. [PMID: 28358995 DOI: 10.1080/09537104.2017.1293809] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This paper provides an overview of the various types of microfluidic devices that are employed to study the complex processes of platelet activation and blood coagulation in whole blood under flow conditions. We elaborate on how these devices are used to detect impaired platelet-dependent fibrin formation in blood from mice or patients with specific bleeding disorders. We provide a practical guide on how to assess formation of a platelet-fibrin thrombus under flow, using equipment that is present in most laboratories. In addition, we describe current insights on how blood flow and shear rate alter the location of platelet populations, von Willebrand factor, coagulation factors, and fibrin in a growing thrombus. Finally, we discuss possibilities and limitations for the clinical use of microfluidic devices to evaluate a hemostatic or prothrombotic tendency in patient blood samples.
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Affiliation(s)
- Magdolna Nagy
- a Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht University , Maastricht , The Netherlands
| | - Johan W M Heemskerk
- a Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht University , Maastricht , The Netherlands
| | - Frauke Swieringa
- a Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM) , Maastricht University , Maastricht , The Netherlands.,b Department of Bioanalytics , Leibniz Institute for Analytical Sciences - ISAS- e.V. , Dortmund , Germany
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30
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The effect of continuous elimination methods on the hemostatic profile of a cardiac surgery patient monitored using thromboelastography. Int J Artif Organs 2016; 39:106-13. [PMID: 27102694 DOI: 10.5301/ijao.5000490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION This work is focused on mapping issues of hemostasis in patients during continuous renal replacement therapy, or the possible impact of the use of anticoagulants. METHODS The study included 30 consecutive patients requiring continuous renal replacement therapy following cardiac surgery in the period of 2009 to 2012. Patients were placed into 2 branches according to the selected method of anticoagulation (regional citrate anticoagulation-RCA, unfractionated heparin UFH). According to the given scheme (t1-t7) thromboelastography and laboratory testing related to the testing of blood clotting during continuous renal replacement therapy were performed. RESULTS The average lifespan of a hemofilter during continuous renal replacement is 58.13 ± 9.968 hours. During continuous renal replacement therapy there are significant changes in the initiation of coagulation according to thromboelastographic parameters (R, K, alpha angle) in both branches of anticoagulation. The maximum image changes in hemostasis occur around 24 hours (t4) from the start of the procedure. The nature of the changes is the procoagulant activity in these parameters. In the branch of regional citrate anticoagulation a higher value of functional fibrinogen is apparent. There was no significant difference in the activation of native blood between UFH and RCA. CONCLUSIONS During continuous renal replacement therapy significant changes occur in the thromboelastographic image and the laboratory parameters in blood clotting. The nature of the change is the procoagulant activity. The question remains about the complexity of the changes that TEG is not able to detect, especially in the cellular area.
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Williams P, Yang K, Kershaw G, Wong G, Dunkley S, Kam PCA. The effects of haemodilution with hydroxyethyl starch 130/0.4 solution on coagulation as assessed by thromboelastography and platelet receptor function studies in vitro. Anaesth Intensive Care 2016; 43:734-9. [PMID: 26603798 DOI: 10.1177/0310057x1504300611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study evaluated the effects of haemodilution with either 6% hydroxyethyl starch (HES) 130/0.4 (Voluven(®)) or 0.9% normal saline (NS) on blood coagulation in vitro. Haemodilution with 6% HES 130/0.4 impaired coagulation, as indicated by the changes in thromboelastographic parameters k-time, α-angle and maximum amplitude. Light transmission aggregometry and multiple electrode aggregometry demonstrated that impaired platelet receptor function occurred only at high levels of haemodilution (40%) with both fluids, but there was no significant difference between the two fluids (P=0.05). The thromboelastographic functional fibrinogen assay showed that the fibrinogen component of clot strength was significantly impaired with haemodilution with HES 130/0.4 compared with haemodilution with NS (whole blood [14.4 ± 4.6 mm] versus 40% HES dilution [3.7 ± 1.9], [P=0.001]; versus 40% NS dilution [10.4 ± 4.6], [P=0.129]). These findings suggest that there is little difference between HES or NS in relation to coagulation or platelet function during minor or moderate haemodilution, but at high levels of haemodilution with HES, fibrinogen activity is more impaired compared with NS.
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Affiliation(s)
- P Williams
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - K Yang
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G Kershaw
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G Wong
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - S Dunkley
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P C A Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
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Mace H, Lightfoot N, McCluskey S, Selby R, Roy D, Timoumi T, Karkouti K. Validity of Thromboelastometry for Rapid Assessment of Fibrinogen Levels in Heparinized Samples During Cardiac Surgery: A Retrospective, Single-center, Observational Study. J Cardiothorac Vasc Anesth 2016; 30:90-5. [DOI: 10.1053/j.jvca.2015.04.030] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Indexed: 11/11/2022]
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Swieringa F, Lancé MD, Fuchs B, Feijge MAH, Solecka BA, Verheijen LPJ, Hughes KR, van Oerle R, Deckmyn H, Kannicht C, Heemskerk JWM, van der Meijden PEJ. Desmopressin treatment improves platelet function under flow in patients with postoperative bleeding. J Thromb Haemost 2015; 13:1503-13. [PMID: 25988848 DOI: 10.1111/jth.13007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 05/05/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients undergoing major cardiothoracic surgery are subjected to dilution, owing to massive fluid infusion and blood component transfusion. These patients may experience bleeding perioperatively, and are frequently treated with the endothelium-activating agent desmopressin. OBJECTIVES To investigate the effect of desmopressin administration on von Willebrand factor (VWF)-dependent coagulant and platelet functions under flow conditions. PATIENTS/METHODS Blood from 16 patients with postoperative bleeding was obtained before and after desmopressin treatment (0.3 μg kg(-1) body weight), and assessed for coagulant properties and platelet function. Furthermore, VWF antigen levels and multimer composition were determined in both samples. RESULTS Desmopressin treatment did not change thrombin generation in plasma or whole blood thromboelasticity. Also coagulation factor levels (other than factor VIII) and coagulation times were unchanged, suggesting that desmopressin treatment did not have a major effect on the coagulant activity. On the other hand, desmopressin treatment raised the already high plasma levels of VWF from a median of 116 IU mL(-1) (interquartile range [IQR] 102-154 IU mL(-1) ) to a median of 160 IU mL(-1) (IQR 126-187 IU mL(-1) ) (P = 0.007), owing to accumulation of the high molecular weight VWF multimers. Furthermore, desmopressin treatment caused an increase in collagen-dependent thrombus formation and platelet phosphatidylserine exposure. Markers of thrombus formation correlated with the plasma levels of VWF. In vitro control experiments confirmed a major contribution of VWF to thrombus formation and procoagulant activity under conditions of blood dilution. CONCLUSIONS Desmopressin treatment of patients with bleeding complications after cardiothoracic surgery induces the release of high molecular weight VWF multimers, which enhance platelet activation and thrombus formation under flow conditions.
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Affiliation(s)
- F Swieringa
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - M D Lancé
- Department of Anesthesiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - B Fuchs
- Department of Molecular Biochemistry Berlin, Octapharma R&D, Berlin, Germany
| | - M A H Feijge
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - B A Solecka
- Department of Molecular Biochemistry Berlin, Octapharma R&D, Berlin, Germany
| | - L P J Verheijen
- Department of Anesthesiology, Diakonessenhuis, Utrecht, the Netherlands
| | - K R Hughes
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - R van Oerle
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - H Deckmyn
- Laboratory for Thrombosis Research, IRF-Life Sciences, KU Leuven Kulak, Kortrijk, Belgium
| | - C Kannicht
- Department of Molecular Biochemistry Berlin, Octapharma R&D, Berlin, Germany
| | - J W M Heemskerk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - P E J van der Meijden
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
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Minami H, Nogami K, Ogiwara K, Furukawa S, Hosokawa K, Shima M. Use of a microchip flow-chamber system as a screening test for platelet storage pool disease. Int J Hematol 2015; 102:157-62. [DOI: 10.1007/s12185-015-1819-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/19/2015] [Accepted: 06/02/2015] [Indexed: 11/30/2022]
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Erdoes G, Gerster G, Colucci G, Kaiser H, Alberio L, Eberle B. Prediction of Post-Weaning Fibrinogen Status during Cardiopulmonary Bypass: An Observational Study in 110 Patients. PLoS One 2015; 10:e0126692. [PMID: 26011420 PMCID: PMC4444179 DOI: 10.1371/journal.pone.0126692] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/13/2015] [Indexed: 12/13/2022] Open
Abstract
Background After cardiac surgery with cardiopulmonary bypass (CPB), acquired coagulopathy often leads to post-CPB bleeding. Though multifactorial in origin, this coagulopathy is often aggravated by deficient fibrinogen levels. Objective To assess whether laboratory and thrombelastometric testing on CPB can predict plasma fibrinogen immediately after CPB weaning. Patients / Methods This prospective study in 110 patients undergoing major cardiovascular surgery at risk of post-CPB bleeding compares fibrinogen level (Clauss method) and function (fibrin-specific thrombelastometry) in order to study the predictability of their course early after termination of CPB. Linear regression analysis and receiver operating characteristics were used to determine correlations and predictive accuracy. Results Quantitative estimation of post-CPB Clauss fibrinogen from on-CPB fibrinogen was feasible with small bias (+0.19 g/l), but with poor precision and a percentage of error >30%. A clinically useful alternative approach was developed by using on-CPB A10 to predict a Clauss fibrinogen range of interest instead of a discrete level. An on-CPB A10 ≤10 mm identified patients with a post-CPB Clauss fibrinogen of ≤1.5 g/l with a sensitivity of 0.99 and a positive predictive value of 0.60; it also identified those without a post-CPB Clauss fibrinogen <2.0 g/l with a specificity of 0.83. Conclusions When measured on CPB prior to weaning, a FIBTEM A10 ≤10 mm is an early alert for post-CPB fibrinogen levels below or within the substitution range (1.5–2.0 g/l) recommended in case of post-CPB coagulopathic bleeding. This helps to minimize the delay to data-based hemostatic management after weaning from CPB.
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Affiliation(s)
- Gabor Erdoes
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
- * E-mail:
| | - Germaine Gerster
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
| | | | - Heiko Kaiser
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
| | - Lorenzo Alberio
- Hématologie non-maligne et Hémostase, Service et Laboratoire central d`Hématologie, University Hospital Lausanne, Lausanne, Switzerland
| | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy, University Hospital Bern, Bern, Switzerland
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Pathirana S, Wong G, Williams P, Yang K, Kershaw G, Dunkley S, Kam PCA. The Effects of Haemodilution with Albumin on Coagulation in Vitro as Assessed by Rotational Thromboelastometry. Anaesth Intensive Care 2015; 43:187-92. [DOI: 10.1177/0310057x1504300207] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We investigated the in vitro viscoelastic changes of progressive haemodilution with 4% albumin compared with normal saline (NS) using rotational thromboelastometry (ROTEM®, Pentapharm Co., Munich, Germany). Whole blood samples obtained from 20 healthy volunteers were diluted in vitro with 4% albumin or NS by 10%, 20% and 40%. Fibrinogen concentration and ROTEM® (EXTEM [screening test for the extrinsic haemostasis system], FIBTEM [EXTEM-based assay for the fibrin part of the clot]) variables including coagulation time, clot formation time (CFT), α-angle, maximum clot firmness and lysis index were measured in the undiluted sample and at each degree of haemodilution. There was no significant difference in fibrinogen concentration at equivalent haemodilutions with normal saline and 4% albumin solutions. Forty percent haemodilution with albumin significantly prolonged coagulation time (EXTEM P=0.007, FIBTEM P=0.0001) and significantly decreased lysis index (FIBTEM P=0.009) compared with NS. A significant decrease in maximum clot firmness from undiluted measurements ( P=0.05) was observed at lower haemodilutions with albumin (20% with EXTEM, 10% with FIBTEM) compared with NS (40% with EXTEM and FIBTEM). The adverse effects of large degrees of haemodilution with 4% albumin solution are in excess of what can be explained by haemodilution alone. This study suggests that large degrees of haemodilution with albumin impair fibrinogen activity to a greater extent than equivalent degrees of haemodilution with NS.
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Affiliation(s)
- S. Pathirana
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G. Wong
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P. Williams
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - K. Yang
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - G. Kershaw
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - S. Dunkley
- Department of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales
| | - P. C. A. Kam
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales
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Modular extracorporeal life support: effects of ultrafiltrate recirculation on the performance of an extracorporeal carbon dioxide removal device. ASAIO J 2014; 60:335-41. [PMID: 24614356 DOI: 10.1097/mat.0000000000000070] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The combination of extracorporeal carbon dioxide removal (ECCO2R) and hemofiltration is a possible therapeutic strategy for patients needing both lung and renal support. We tested the effects of the recirculation of ultrafiltrate on membrane lung (ML) CO2 removal (VCO2ML). Three conscious, spontaneously breathing sheep were connected to a commercially produced ECCO2R device (Hemolung; Alung Technologies, Pittsburgh, PA) with a blood flow of 250 ml/min and a gas flow of 10 L/min. A hemofilter (NxStage, NxStage Medical, Lawrence, MA) was interposed in series after the ML. Ultrafiltrate flow was generated and recirculated before the ML. We tested four ultrafiltrate flows (0, 50, 100, and 150 ml/min) for 25 min each, eight times per animal, resulting in 24 randomized test repetitions. We recorded VCO2ML, hemodynamics and ventilatory variables, and natural lung CO2 transfer (VCO2NL) and collected arterial and circuitry blood samples. VCO2ML was unchanged by application of ultrafiltrate recirculation (40.5 ± 4.0, 39.7 ± 4.2, 39.8 ± 4.2, and 39.2 ± 4.1 ml/min, respectively, at ultrafiltrate flow of 0, 50, 100, and 150 ml/min). Minute ventilation, respiratory rate, VCO2NL, and arterial blood analyses were not affected by ultrafiltrate recirculation. In the tested configuration, ultrafiltrate recirculation did not affect VCO2ML. This modular technology may provide a suitable platform for coupling CO2 removal with various forms of blood purification.
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Besser MW, Ortmann E, Klein AA. Haemostatic management of cardiac surgical haemorrhage. Anaesthesia 2014; 70 Suppl 1:87-95, e29-31. [DOI: 10.1111/anae.12898] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2014] [Indexed: 11/28/2022]
Affiliation(s)
- M. W. Besser
- Department of Haematology; Papworth Hospital; Cambridge UK
| | - E. Ortmann
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
- Department of Anaesthesia and Intensive Care; Kerckhoff Klinik Heart and Lung Centre; Bad Nauheim Germany
| | - A. A. Klein
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
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Tanaka K, Esper S, Bolliger D. Perioperative factor concentrate therapy. Br J Anaesth 2013; 111 Suppl 1:i35-49. [DOI: 10.1093/bja/aet380] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Ogawa S, Hosokawa K, Tanaka KA. Influences of Hemodilution and Anticoagulation on Antiplatelet P2Y12 Therapy: In Vitro Whole Blood Perfusion Model. J Cardiothorac Vasc Anesth 2013; 27:e69-71. [DOI: 10.1053/j.jvca.2013.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Indexed: 11/11/2022]
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Guzzetta NA, Szlam F, Kiser AS, Fernandez JD, Szlam AD, Leong T, Tanaka KA. Augmentation of thrombin generation in neonates undergoing cardiopulmonary bypass. Br J Anaesth 2013; 112:319-27. [PMID: 24193321 DOI: 10.1093/bja/aet355] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Factor concentrates are currently available and becoming increasingly used off-label for treatment of bleeding. We compared recombinant activated factor VII (rFVIIa) with three-factor prothrombin complex concentrate (3F-PCC) for the ability to augment thrombin generation (TG) in neonatal plasma after cardiopulmonary bypass (CPB). First, we used a computer-simulated coagulation model to assess the impact of rFVIIa and 3F-PCC, and then performed similar measurements ex vivo using plasma from neonates undergoing CPB. METHODS Simulated TG was computed according to the coagulation factor levels from umbilical cord plasma and the therapeutic levels of rFVIIa, 3F-PCC, or both. Subsequently, 11 neonates undergoing cardiac surgery were enrolled. Two blood samples were obtained from each neonate: pre-CPB and post-CPB after platelet and cryoprecipitate transfusion. The post-CPB products sample was divided into control (no treatment), control plus rFVIIa (60 nM), and control plus 3F-PCC (0.3 IU ml(-1)) aliquots. Three parameters of TG were measured ex vivo. RESULTS The computer-simulated post-CPB model demonstrated that rFVIIa failed to substantially improve lag time, TG rate and peak thrombin without supplementing prothrombin. Ex vivo data showed that addition of rFVIIa post-CPB significantly shortened lag time; however, rate and peak were not statistically significantly improved. Conversely, 3F-PCC improved all TG parameters in parallel with increased prothrombin levels in both simulated and ex vivo post-CPB samples. CONCLUSIONS Our data highlight the importance of prothrombin replacement in restoring TG. Despite a low content of FVII, 3F-PCC exerts potent procoagulant activity compared with rFVIIa ex vivo. Further clinical evaluation regarding the efficacy and safety of 3F-PCC is warranted.
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Affiliation(s)
- N A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
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Schött U, Johansson PI. II. Bringing flow into haemostasis diagnostics. Br J Anaesth 2013; 111:864-7. [PMID: 24124183 DOI: 10.1093/bja/aet289] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- U Schött
- Department of Intensive Care and Perioperative Care, Skane University Hospital, Lund and Lund University, Lund, Sweden
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