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Joung GI, Bae JY, Kim JI, Kim JY, Song JH. Evaluation of clopidogrel, hypercoagulability, and platelet count in dogs undergoing splenectomy for splenic masses. Vet Q 2024; 44:1-8. [PMID: 38823415 PMCID: PMC11146242 DOI: 10.1080/01652176.2024.2347926] [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: 09/25/2023] [Accepted: 04/21/2024] [Indexed: 06/03/2024] Open
Abstract
Dogs that had splenectomy are predisposed to fatal thrombotic conditions, and thrombocytosis is a risk factor for post-splenectomy hypercoagulability. However, in veterinary medicine, there are no specific therapeutic approaches for managing this hypercoagulability. This study aimed to determine the preventive effect of clopidogrel on post-operative hypercoagulability during the first 2 weeks post-splenectomy in dogs with splenic masses. This study included 12 dogs that had splenectomy. Seven dogs received no treatment (group A), and five were treated with clopidogrel (group B). Clopidogrel was loaded at 10 mg/kg on day 2 and continued at 2 mg/kg until day 14. Blood samples were collected on the day of surgery and 2, 7, and 14 days after splenectomy in both groups. In group B, thromboelastography (TEG) was performed on the same days. In group A, there was significant elevation of platelet counts on days 7 (p = 0.007) and 14 (p = 0.001) compared to day 0. In group B, the platelet counts were significantly elevated on day 7 (p = 0.032) but no significant difference was found on day 14 compared to day 0. Platelet counts on day 14 were significantly higher in group A than in group B (p = 0.03). The lower platelet counts were correlated with alterations in TEG parameters, and no significant differences were found in the K and α-angle values at all postoperative assessment points compared to day 0. Our study suggests that clopidogrel may reduce post-operative thrombocytosis and hypercoagulability in dogs that undergo splenectomy for splenic masses.
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Affiliation(s)
- Guk-Il Joung
- Department of Veterinary Internal Medicine, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Jeong-Yeol Bae
- Department of Veterinary Internal Medicine, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Jung-Il Kim
- Department of Veterinary Internal Medicine, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Jin-Young Kim
- Department of Veterinary Internal Medicine, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
| | - Joong-Hyun Song
- Department of Veterinary Internal Medicine, College of Veterinary Medicine, Chungnam National University, Daejeon, South Korea
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Xue-Xing W, Jie C, Chun-Mei C, Yuan H, Chun-Mei W. Analyzing venous thromboembolism risk in malignant tumors: thromboelastogram and coagulation factors study. Biomark Med 2024; 18:373-383. [PMID: 39041842 DOI: 10.1080/17520363.2024.2342239] [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: 08/30/2023] [Accepted: 03/26/2024] [Indexed: 07/24/2024] Open
Abstract
Aim: This retrospective clinical study was designed to examine the predictive value of thromboelastography (TEG) combined with coagulation function for venous thromboembolism (VTE) in hospitalized patients with cancer. Materials & methods: Among 215 patients admitted between May 2020 and January 2022, 39 (18.14%) were diagnosed with VTE during hospitalization. Results: Significant differences were found in D-dimer, ATIII and TEG parameters (maximum amplitude and coagulation index) between VTE-positive and VTE-negative patients (p < 0.05). Multivariate analysis revealed tumor node metastasis stage, concomitant infection, smoking history and D-dimer as independently associated with VTE. The constructed model and D-dimer areas under the curve were 0.809 and 0.764, respectively. Conclusion: TEG parameters were not significantly predictive indicators for VTE, with D-dimer remaining a key predictor.
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Affiliation(s)
- Wang Xue-Xing
- Department of Oncology, Anning First People's Hospital Affiliated to Kunming University of Science and Technology, Kunming, 650300, China
| | - Chu Jie
- Department of Oncology, Ziyang Hospital, West China Hospital, Sichuan University, Ziyang, 641300, China
| | - Chen Chun-Mei
- Department of Pharmacy, Anning First People's Hospital Affiliated to Kunming University of Science and Technology, Kunming, 650300, China
| | - He Yuan
- The Third Affiliated Hospital of Kunming Medical University, Kunming, 650000, China
| | - Wei Chun-Mei
- Department of Oncology, Anning First People's Hospital Affiliated to Kunming University of Science and Technology, Kunming, 650300, China
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Clarkin-Breslin RC, Chalifoux NV, Buriko Y. Standard tests of haemostasis do not predict elevated thromboelastographic maximum amplitude, an index of hypercoagulability, in sick dogs. J Small Anim Pract 2024. [PMID: 38804082 DOI: 10.1111/jsap.13741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 04/04/2024] [Accepted: 04/17/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVES To compare standard tests of haemostasis in hypercoagulable and normocoagulable sick dogs as identified by thromboelastography. MATERIALS AND METHODS We compared prothrombin time, activated partial thromboplastin time, D-dimers, packed red blood cell volume and platelet counts in client-owned sick dogs with hypercoagulable (n = 36) and normocoagulable (n = 35) states as identified by thromboelastography maximum amplitude above or within the established reference interval, respectively. RESULTS Seventy-one dogs were included. Thirty-six dogs were hypercoagulable and 35 were normocoagulable on thromboelastography. Using multivariable linear models, prothrombin time, activated partial thromboplastin time and D-dimers were not associated with hypercoagulability. Platelet counts and packed red blood cell volume were significantly associated with hypercoagulability. CLINICAL SIGNIFICANCE Prothrombin time, activated partial thromboplastin time and D-dimers were not useful in the identification of hypercoagulability in dogs as defined by thromboelastography.
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Affiliation(s)
- R C Clarkin-Breslin
- Department of Clinical Sciences and Advanced Medicine, Veterinary Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - N V Chalifoux
- Department of Clinical Sciences and Advanced Medicine, Veterinary Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Y Buriko
- Department of Clinical Sciences and Advanced Medicine, Veterinary Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Yang Z, Xie L, Ba J, Zan S, Zhang L, Zhang X, Yu Y. Comparative studies between humans and golden Syrian hamsters via thromboelastography. Animal Model Exp Med 2024. [PMID: 38769667 DOI: 10.1002/ame2.12403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/27/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Thromboelastography (TEG) is a widely utilized clinical testing method for real-time monitoring of platelet function and the thrombosis process. Lipid metabolism disorders are crucial risk factors for thrombosis. The lipid metabolism characteristics of hamsters resemble those of humans more closely than mice and rats, and their relatively large blood volume makes them suitable for studying the mechanisms of thrombosis related to plasma lipid mechanisms. Whole blood samples from golden Syrian hamsters and healthy humans were obtained following standard clinical procedures. TEG was employed to evaluate coagulation factor function, fibrinogen (Fib) function, platelet function, and the fibrinolytic system. METHODS The whole blood from hamster or healthy human was isolated following the clinical procedure, and TEG was employed to evaluate the coagulation factor function, Fib function, platelet function, and fibrinolytic system. Coagulation analysis used ACLTOP750 automatic coagulation analysis pipeline. Blood routine testing used XN-2000 automatic blood analyzer. RESULTS TEG parameters revealed that hamsters exhibited stronger coagulation factor function than humans (reaction time [R], p = 0.0117), with stronger Fib function (alpha angle, p < 0.0001; K-time [K], p < 0.0001). Platelet function did not differ significantly (maximum amplitude [MA], p = 0.077). Hamsters displayed higher coagulation status than humans (coagulation index [CI], p = 0.0023), and the rate of blood clot dissolution in hamsters differed from that in humans (percentage lysis 30 min after MA, p = 0.02). Coagulation analysis parameters indicated that prothrombin time (PT) and activated partial thromboplastin time (APTT) were faster in hamsters than in humans (PT, p = 0.0014; APTT, p = 0.03), whereas the Fib content was significantly lower in hamsters than in humans (p < 0.0001). No significant difference was observed in thrombin time (p = 0.1949). CONCLUSIONS In summary, TEG could be used to evaluate thrombosis and bleeding parameters in whole blood samples from hamsters. The platelet function of hamsters closely resembled that of humans, whereas their coagulation function was significantly stronger.
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Affiliation(s)
- Ze Yang
- School of Laboratory Animal & Shandong Laboratory Animal Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
- The Second Affiliated Hospital of Shandong First Medical University, Taian, China
| | - Lili Xie
- The Second Affiliated Hospital of Shandong First Medical University, Taian, China
| | - Jingjing Ba
- School of Laboratory Animal & Shandong Laboratory Animal Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
- The Second Affiliated Hospital of Shandong First Medical University, Taian, China
| | - Simin Zan
- School of Laboratory Animal & Shandong Laboratory Animal Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
| | - Letong Zhang
- School of Laboratory Animal & Shandong Laboratory Animal Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
| | - Xinyi Zhang
- School of Laboratory Animal & Shandong Laboratory Animal Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
| | - Yang Yu
- School of Laboratory Animal & Shandong Laboratory Animal Center, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, China
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Favors L, Harrell K, Miles V, Hicks RC, Rippy M, Parmer H, Edwards A, Brown C, Stewart K, Day L, Wilson A, Maxwell R. Analysis of fibrinolytic shutdown in trauma patients with traumatic brain injury. Am J Surg 2024; 227:72-76. [PMID: 37802703 DOI: 10.1016/j.amjsurg.2023.09.034] [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: 06/30/2023] [Revised: 09/01/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Coagulation profiles following major trauma vary depending on injury pattern and degree of shock. The physiologic mechanisms involved in coagulation function at any given time are varied and remain poorly understood. Thromboelastography (TEG) has been used evaluate coagulation profiles in the trauma population with some reports demonstrating a spectrum of fibrinolysis to fibrinolytic shutdown on initial presentation. The objective of this study was to evaluate the fibrinolytic profile of patients with TBI using thromboelastography (TEG). We hypothesized that patients with TBI would demonstrate low fibrinolytic activity. METHODS All trauma activations at an ACS-verified level 1 trauma center received a TEG analysis upon arrival from December 2019 to June 2021. A retrospective review of the results and outcomes was conducted, and TBI patients were compared to patients without TBI. Linear regression was used to evaluate the effect of patient and injury factors on fibrinolysis. Hyperfibrinolysis was defined as LY30 > 7.7%, physiologic fibrinolysis as LY30 0.6-7.7%, and fibrinolytic shutdown as LY30 < 0.6%. RESULTS A total of 1369 patients received an admission TEG analysis. Patients with TBI had a significantly higher median ISS (16 vs. 8, p < 0.001), lower median admission Glasgow Coma Scale (14 vs. 15, p < 0.001), longer intensive care unit length of stay (3 vs. 2 days, p < 0.0001), increased ventilator days (216 vs. 183, p < 0.001), higher mortality (14.6% vs. 5.1%, p < 0.001), but lower shock index (0.6 vs. 0.7, p < 0.0001) compared to those without TBI. Median LY30 was found to be decreased in the TBI group (0.1 vs. 0.2, p = 0.0006). Patients with TBI were found to have a higher rate of fibrinolytic shutdown compared those without TBI (68.7% vs. 63.5%, p = 0.054). ISS, sex, and shock index were found to be predictive of LY30 on linear regression, but TBI was not (Β: 0.09, SE: 0.277, p = 0.745). The rate of DVT/PE did not appear to be elevated in patients with TBI (0.8%) and without TBI (1.2%). CONCLUSIONS Trauma patients with and without TBI were found to have high rates of fibrinolytic shutdown. Although there was a high incidence of fibrinolytic shutdown, it did not appear to have an impact on the rate of thrombotic complications. The clinical significance of these results is unclear and differs significantly from recent reports which demonstrated that TBI is associated with a 25% rate of fibrinolytic shutdown. Further investigation is needed to better define the fibrinolytic pathway in patients with trauma and TBI to develop optimal treatment algorithms.
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Affiliation(s)
- L Favors
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - K Harrell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - V Miles
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
| | - R C Hicks
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - M Rippy
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - H Parmer
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - A Edwards
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - C Brown
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - K Stewart
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - L Day
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - A Wilson
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA
| | - R Maxwell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, 979 East Third Street, Suite B-401, Chattanooga, TN, 37403, USA.
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Mishra L, Lee D, Ho KM. Incidence of factor XII deficiency in critically ill patients with a prolonged activated partial thromboplastin time: a prospective observational study. Blood Coagul Fibrinolysis 2023; 34:364-369. [PMID: 37395184 DOI: 10.1097/mbc.0000000000001235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Limited data is available on factor XII deficiency in critically ill patients with prolonged activated partial thromboplastin time (aPTT). The association of factor XII deficiency with an increased risk of thromboembolism is unclear. This prospective observational study assessed the incidence of factor XII deficiency among critically ill patients with prolonged aPTT (>40 s), whether factor XII deficiency manifesting as prolonged aPTT was associated with an increased risk of thromboembolism, and clotting time on a viscoelastic (ROTEM) test was useful to predict factor XII deficiency. Of the 40 included patients, 48% [95% confidence interval (CI) 33-63) had a factor XII deficiency (mean ± standard deviation of factor XII level of all patients: 54% ± 29%). Factor XII levels were not significantly correlated with the measured aPTT ( r = -0.163, P = 0.315). Factor XII deficiency was significantly more common in patients who were less critically ill ( P = 0.027), but it was not significantly related to Disseminated Intravascular Coagulation scores ( P = 0.567). The incidence of symptomatic venous thromboembolism ( P = 0.246), allogeneic blood transfusion ( P = 0.816), and hospital mortality ( P = 0.201) were not significantly different between those with and without factor XII deficiency. The clotting time on the viscoelastic test was not predictive of factor XII deficiency (area under the receiver-operating characteristic = 0.605, P = 0.264). Factor XII deficiency was common in critically ill patients with a prolonged aPTT. There was no association between factor XII deficiency and risk of thromboembolism. The clotting time on ROTEM was not predictive of the presence of factor XII deficiency.
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Affiliation(s)
- Lipi Mishra
- Medical School, University of Western Australia, and School of Veterinary & Life Sciences, Murdoch University, Intensive Care Unit, Royal Perth Hospital, Western Australia, Australia
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Buckley MS, Benanti GE, Gilbert B, Meckel J, Dzierba AL, MacLaren R. Correlation between heparin anti-Xa activity and thromboelastography in adult critically ill COVID-19 patients. Pharmacotherapy 2023; 43:795-803. [PMID: 37199139 DOI: 10.1002/phar.2829] [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: 12/15/2022] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 05/19/2023]
Abstract
STUDY OBJECTIVE Severe coronavirus disease 2019 (COVID-19) increases the risk of thrombotic complications with unfractionated heparin (UFH) as a commonly used agent in managing venous thromboembolism (VTE). The optimal anticoagulation intensity and monitoring parameters in intensive care unit (ICU) COVID-19 patients remains controversial. The primary study aim was to evaluate the relationship between anti-Xa and thromboelastography (TEG) reaction (R) time in patients with severe COVID-19 receiving therapeutic UFH infusions. DESIGN Single-center, retrospective study conducted over a 15-month period (2020-2021). SETTING Academic medical center (Banner University Medical Center Phoenix). PATIENTS Adult patients with severe COVID-19 administered therapeutic UFH infusions with one or more corresponding TEG, and anti-Xa assessments drawn within ≤2 hours of each other were included. The primary end point was the correlation between anti-Xa and TEG R time. Secondary aims were to describe the correlation between activated partial thromboplastin time (aPTT) and TEG R time, as well as clinical outcomes. Pearson's coefficient was used to evaluate the correlation using a kappa measure of agreement.
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Affiliation(s)
- Mitchell S Buckley
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Grace E Benanti
- Department of Pharmacy, Loyola University Medical Center, Maywood, Illinois, USA
| | - Brian Gilbert
- Department of Pharmacy, Wesley Medical Center, Wichita, Kansas, USA
| | - Jordan Meckel
- Department of Pharmacy, Banner University Medical Center Phoenix, Phoenix, Arizona, USA
| | - Amy L Dzierba
- Department of Pharmacy, New York-Presbyterian Hospital, New York, New York, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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Prevalence of Venous Thromboembolism in Intensive Care Units: A Meta-Analysis. J Clin Med 2022; 11:jcm11226691. [PMID: 36431168 PMCID: PMC9698016 DOI: 10.3390/jcm11226691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a life threating complication in intensive care units (ICUs). This study aimed to pool the prevalence of VTE and examined the risk factors of VTE in intensive care patients worldwide. METHODS A systematic search in PubMed, EMBASE and Web of Science databases was performed. Studies reported that the data on the prevalence of VTE or relevant information were synthesized using a random-effects model. RESULTS A total of 42 studies reporting on 27,344 patients were included. The pooled prevalence of VTE was 10.0% (95% CI: 7.0-14.0%). Subgroup and metaregression analyses found that thromboprophylaxis strategy, simplified acute physiology score (SAPS II), age, study quality, sample size, malignancy, sex, spinal cord injury and injury severity score (ISS) moderated the prevalence of VTE in intensive care patients. CONCLUSIONS The present meta-analysis revealed a high prevalence of VTE in critically ill patients. The risk factors of VTE included thromboprophylaxis strategy, SAPS II, age, malignancy, sex, spinal cord injury and ISS. Therefore, we need to pay more attention to high-risk populations of VTE in intensive care patients.
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Favors LE, Harrell KN, Miles MVP, Everett H, Rippy M, Maxwell R. Analysis of Admission Thromboelastogram Profiles in 1369 Male and Female Trauma Patients. J Surg Res 2022; 280:551-556. [PMID: 36096020 DOI: 10.1016/j.jss.2022.07.048] [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: 03/01/2022] [Revised: 06/13/2022] [Accepted: 07/28/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Recent studies have demonstrated a hypercoagulable thromboelastrogram (TEG) in female trauma patients compared with males, conferring a possible survival advantage. We hypothesized that TEG profiles would reveal a relative hypercoagulable state in female compared with male trauma patients. METHODS A prospective review was conducted on all adult trauma patients admitted to the trauma service at an American College of Surgeons-verified level I trauma center from December 2019 to June 2021 who, per our institutional protocol, received a thrombelastotgraphy on their initial arrival to the trauma center if classified as a level I or II trauma activation. The thromboelastography values of male and female trauma patients were compared as the primary outcome variables of interest. The secondary outcomes investigated were hospital length of stay, surgical interventions, and ventilatory requirement. RESULTS A total of 1369 patients met inclusion criteria, with 878 (64.1%) male and 491 (35.9%) female. Female patients had a higher median alpha angle (74.8 versus 72.6°, P < 0.001), maximum amplitude (69.3 versus 66.2 mm, P < 0.001), and shorter median K time (1.0 versus 1.2 s, P < 0.001). Female patients had a shorter hospital length of stay (4 versus 5 d, P < 0.001), had a lower rate of surgical intervention (14.6% versus 25.5%, P < 0.001), and had lower rates of mechanical ventilation (19.3% versus 39.5%, P < 0.001). CONCLUSIONS Female trauma patients were found to have hypercoagulable indices on TEG at the time of initial trauma evaluation compared with males. Intrinsic differences in sex coagulation profiles should be further investigated to optimize modern resuscitation strategies.
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Affiliation(s)
- Lauren E Favors
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee.
| | - Kevin N Harrell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - M Victoria P Miles
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Hayley Everett
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
| | - Meredith Rippy
- University of Tennessee Chattanooga, Chattanooga, Tennessee
| | - Robert Maxwell
- Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, Tennessee
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He Y, Yao H, Ageno W, Méndez-Sánchez N, Guo X, Qi X. Review article: thromboelastography in liver diseases. Aliment Pharmacol Ther 2022; 56:580-591. [PMID: 35698893 DOI: 10.1111/apt.17080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/16/2022] [Accepted: 05/29/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Patients with liver diseases have complicated haemostatic alternations, resulting in both bleeding and thromboembolic complications, which cannot be sufficiently evaluated by conventional coagulation tests (CCTs), such as platelet count or prothrombin time. Thromboelastography (TEG) is a whole blood viscoelastic test which globally reflects changes in the haemostatic system, and its utility in evaluating patients with liver disease is increasingly recognised. AIMS To review the current evidence and clinical significance of TEG in liver diseases. METHODS Literature regarding TEG and liver diseases was comprehensively searched. RESULTS TEG is associated closely with the severity and aetiology of liver disease, the course of infection and the risk of bleeding and death, but not the risk of portal venous system thrombosis. Additionally, TEG-guided transfusion protocols can significantly decrease the requirement for blood products compared to those guided by CCTs. CONCLUSION TEG can reflect the haemostatic status of liver diseases more comprehensively than CCTs. It has the potential to assess the severity of liver diseases, predict the risk of bleeding and death in patients with liver disease and guide blood product transfusion. Future studies should standardise the use of TEG for assessing disease severity and development of clinical events and guiding blood product transfusion in patients with liver diseases.
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Affiliation(s)
- Yanglan He
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China.,Postgraduate College, China Medical University, Shenyang, China
| | - Haijuan Yao
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Nahum Méndez-Sánchez
- Liver Research Unit Medica Sur Clinic & Foundation and Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
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12
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Harahsheh Y, Ludewick H, Pavey W, Ho KM. Endothelial biomarkers of thrombosis in critically ill patients with acquired coagulopathy: a prospective cohort study. Biomark Med 2022; 16:663-672. [PMID: 35583036 DOI: 10.2217/bmm-2021-0576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: It remains largely unknown whether endothelial biomarkers can be used to predict thromboembolism in critically ill patients with an acquired coagulopathy. Materials & methods: The ability of syndecan-1, P-selectin and microRNA expressions to predict thromboembolism were assessed in 40 critically ill coagulopathic patients. Results: The area under the receiver operating characteristic curves for syndecan-1, P-selectin and the four differentially expressed microRNAs - determined by real-time qPCR analysis - to predict thromboembolism (n = 10, 25%) were 0.71 (95% CI 0.52-0.89), 0.73 (95% CI 0.52-0.95) and >0.80, respectively. Syndecan-1 and P-selectin concentrations were also significantly correlated with one another (R = 0.41, p = 0.008). Conclusion: Endothelial function biomarkers, including endothelial microRNA expressions, were associated with subsequent thromboembolism in critically ill patients who had a deranged coagulation profile.
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Affiliation(s)
- Yusrah Harahsheh
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA, Perth, 6000, Australia.,Medical School, University of Western Australia, Crawley, WA, 6009, Australia
| | - Herbert Ludewick
- Heart & Lung Research Institute of Western Australia, Murdoch, WA, 6150, Australia
| | - Warren Pavey
- Heart & Lung Research Institute of Western Australia, Murdoch, WA, 6150, Australia.,Department of Anaesthesia, Fiona Stanley Hospital, Murdoch, WA, 6150, Australia.,School of Veterinary & Life Sciences, Murdoch University, Murdoch, WA, 6150, Australia
| | - Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA, Perth, 6000, Australia.,Medical School, University of Western Australia, Crawley, WA, 6009, Australia.,School of Veterinary & Life Sciences, Murdoch University, Murdoch, WA, 6150, Australia
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13
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Willis J, Carroll C, Planz V, Galgano SJ. Thromboelastography: a review for radiologists and implications on periprocedural bleeding risk. Abdom Radiol (NY) 2022; 47:2697-2703. [PMID: 35567618 PMCID: PMC9107068 DOI: 10.1007/s00261-022-03539-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 01/18/2023]
Abstract
Thromboelastography (TEG) and rotational thromboelastometry are emerging technologies that are gaining increasing acceptance in the medical field to evaluate the coagulation status of patients on an individual level by assessing dynamic clot formation. TEG has been proven to reduce blood product use as well as improve patient outcomes in a variety of medical settings, including trauma and surgery due to the expediated nature of the test as well as the ability to determine specific deficiencies present in whole blood that are otherwise undetectable with traditional coagulation studies. Currently, no guidelines or recommendations are in place for the utilization of TEG in interventional or diagnostic radiology although access to TEG has become increasingly common in recent years. This manuscript presents a review of prior literature on the technical aspects of TEG as well as its use in various fields and explains the normal TEG-tracing parameters. Common hemodynamic abnormalities and their effect on the TEG tracing are illustrated, and the appropriate treatments for each abnormality are briefly mentioned. TEG has the potential to be a useful tool for determining the hemodynamic state of patients in both interventional and diagnostic radiology, and further research is needed to determine the value of these tests in the periprocedural setting.
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Affiliation(s)
- Joseph Willis
- grid.265892.20000000106344187University of Alabama at Birmingham School of Medicine, Birmingham, AL USA
| | - Caleb Carroll
- grid.265892.20000000106344187University of Alabama at Birmingham School of Medicine, Birmingham, AL USA
| | - Virginia Planz
- grid.412807.80000 0004 1936 9916Department of Radiology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Samuel J. Galgano
- grid.265892.20000000106344187Department of Radiology, University of Alabama at Birmingham, Birmingham, AL USA
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14
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López-Jaime FJ, Fernández-Bello I, Martín-Téllez S, Doblas-Márquez A, Tesfay Y, Márquez-Gómez I, Reguera-Iglesias JM, Muñoz-Pérez MI, Montaño A. Clot Stiffness Measured By Seer Sonorheometry As a Marker Of Poor Prognosis In Hospitalized COVID-19 Patients. Clin Appl Thromb Hemost 2022; 28:10760296221112085. [PMID: 35903939 PMCID: PMC9340415 DOI: 10.1177/10760296221112085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A high risk of thrombotic complications has been observed among severely ill
COVID-19 patients. Viscoelastic tests (VET) have shown a hypercoagulable profile
in these patients, although so far there is no clear evidence on the use of
these tools as predictors of risk in the clinical course of patients. In this
study we aimed to evaluate the association between Quantra® sonorheometry VET
parameters, standard coagulation tests and inflammatory markers in 69 patients
with COVID-19 on hospital admission with disease severity and outcome.
Inflammatory markers were elevated in a high percentage of patients, as were
coagulation-related parameters such as fibrinogen and D-dimer levels. Quantra®
sonorheometry analysis revealed increased clot stiffness (CS), especially due to
increased fibrinogen contribution (FCS) in 63.7%. Analysis of clot stability to
lysis (CSL) on the Quantra showed a value of 100%, suggesting hypofibrinolysis,
in 32.4%. Age > 65 years, elevated values of fibrinogen, D-dimer, LDH,
increased CS and CSL were significantly associated with worsening disease. The
combination of elevated FCS and D-dimer values showed a particularly high
prognostic value in distinguishing patients with severe symptomatology. In
conclusion, FCS measured by Quantra® system and its combination with D-dimer
could be established as a powerful tool to identify poor prognosis in COVID-19
patients on hospital admission.
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Affiliation(s)
| | - Ihosvany Fernández-Bello
- Unidad de Hemostasia y Trombosis, 16330Hospital Universitario Regional de Málaga, IBIMA, Málaga, Spain
| | - Sandra Martín-Téllez
- Unidad de Hemostasia y Trombosis, 16330Hospital Universitario Regional de Málaga, IBIMA, Málaga, Spain
| | - Alberto Doblas-Márquez
- Unidad de Hemostasia y Trombosis, 16330Hospital Universitario Regional de Málaga, IBIMA, Málaga, Spain
| | | | - Ignacio Márquez-Gómez
- Servicio de Enfermedades Infecciosas, 16330Hospital Universitario Regional de Málaga, Málaga, Spain
| | | | - Manuel Isidro Muñoz-Pérez
- Unidad de Hemostasia y Trombosis, 16330Hospital Universitario Regional de Málaga, IBIMA, Málaga, Spain
| | - Adrián Montaño
- Unidad de Hemostasia y Trombosis, 16330Hospital Universitario Regional de Málaga, IBIMA, Málaga, Spain.,Universidad de Salamanca, Salamanca, Spain
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15
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Ankola AA, Bradford VR, Newburger JW, Emani S, Dionne A, Friedman K, Son MB, Henderson LA, Lee PY, Hellinger A, Hawkins B, Ventresco C, Esteso P, VanderPluym CJ. Coagulation profiles and viscoelastic testing in multisystem inflammatory syndrome in children. Pediatr Blood Cancer 2021; 68:e29355. [PMID: 34532964 DOI: 10.1002/pbc.29355] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To characterize viscoelastic testing profiles of children with multisystem inflammatory syndrome in children (MIS-C). METHODS This single-center retrospective review included 30 patients diagnosed with MIS-C from March 1 to September 1, 2020. Thromboelastography (TEG) with platelet mapping was performed in 19 (63%) patients and compared to age- and sex-matched controls prior to cardiac surgery. Relationships between TEG parameters and inflammatory markers were assessed using correlation. RESULTS Patients with MIS-C had abnormal TEG results compared to controls, including decreased kinetic (K) time (1.1 vs. 1.7 minutes, p < .01), increased alpha angle (75.0° vs. 65.7°, p < .01), increased maximum amplitude (70.8 vs. 58.3 mm, p < .01), and decreased lysis in 30 minutes (Ly30) (1.1% vs. 3.7%, p = .03); consistent with increased clot formation rate and strength, and reduced fibrinolysis. TEG maximum amplitude was moderately correlated with erythrocyte sedimentation rate (ESR) (r = 0.60, p = .02), initial platelet count (r = 0.67, p < .01), and peak platelet count (r = 0.51, p = .03). TEG alpha angle was moderately correlated with peak platelet count (r = 0.54, p = .02). Seventeen (57%) patients received aspirin (ASA) and anticoagulation, five (17%) received only ASA, and three (10%) received only anticoagulation. No patients had a symptomatic thrombotic event. Six (20%) patients had a bleeding event, none of which was major. CONCLUSIONS Patients with MIS-C had evidence of hypercoagulability on TEG. Increased ESR and platelets were associated with higher clot strength. Patients were prophylactically treated with ASA or anticoagulation with no symptomatic thrombosis or major bleeding. Further multicenter study is required to characterize the rate of thrombosis and optimal thromboprophylaxis algorithm in this patient population.
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Affiliation(s)
- Ashish A Ankola
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Victoria R Bradford
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sirisha Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kevin Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mary Beth Son
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amy Hellinger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Beth Hawkins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Courtney Ventresco
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Paul Esteso
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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16
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Wan H, Fan X, Wu Z, Lie Z, Li D, Su S. Prevalence and impact of fibrinolytic dysregulation in patients with acute coronary syndromes. Thromb J 2021; 19:33. [PMID: 34022898 PMCID: PMC8141118 DOI: 10.1186/s12959-021-00288-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/14/2021] [Indexed: 01/05/2023] Open
Abstract
Objective Dual antiplatelet therapy can reduce coronary thrombosis and improve the prognosis in patients with acute coronary syndrome (ACS). However, there was limited prognostic information about fibrinolytic dysregulation in patients with ACS. This study is aimed to evaluated the prevalence and impact of fibrinolytic dysregulation in patients with acute coronary syndrome (ACS). Methods We retrospectively analyzed coagulation and fibrinolysis related indexes of ACS in hospitalized adults with rapid thrombelastography between May 2016 and December 2018. All of the follow-up visits were ended by December 2019. The primary outcome was the occurrence of major adverse cardiovascular events (MACEs), which included unstable angina pectoris, non-fatal myocardial infarction, non-fatal cerebral infarction, heart failure and all-cause death. Results Three hundred thirty-eight patients were finally included with an average age of 62.5 ± 12.8 years old, 273 (80.5%) were males, 137(40.5%) patients were with ST-elevation myocardial infraction. Fibrinolysis shutdown (LY30<0.8%) and hyperfibrinolysis (LY30 >3.0%) were observed among 163 (48.2%) and 76(22.5%) patients, respectively. During a total of 603.2 person·years of follow-up period, 77 MACEs occurred (22.8%). Multivariate Cox regression analysis indicated that LY30 [HR: 1.101, 95% CI: 1.010–1.200, P = 0.028] was independently correlated with the occurrence of MACEs. The hazard ratios pertaining to MACEs in patients with fibrinolysis shutdown and hyperfibrinolysis compared with those in the physiologic range (LY30: 0.8–3.0%) were 1.196 [HR: 1.196, 95% CI: 0.679–2.109,P = 0.535] and 2.275 [HR: 2.275, 95% CI: 1.241–4.172, P = 0.003], respectively. Conclusions Fibrinolytic dysregulation is very common in selected patients with ACS, and hyperfibrinolysis (LY30 > 3%) is associated with poor outcomes in patients with ACS.
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Affiliation(s)
- Huaibin Wan
- Department of Cardiology, Dongguan People's Hospital, Southern Medical University, Dongguan, 523059, Guangdong, China.
| | - Xin Fan
- Department of Cardiology, Dongguan People's Hospital, Southern Medical University, Dongguan, 523059, Guangdong, China
| | - Zhihao Wu
- Department of Cardiology, Dongguan People's Hospital, Southern Medical University, Dongguan, 523059, Guangdong, China
| | - Zhenbang Lie
- Department of Cardiology, Dongguan People's Hospital, Southern Medical University, Dongguan, 523059, Guangdong, China
| | - Daqiang Li
- Department of Cardiology, Dongguan People's Hospital, Southern Medical University, Dongguan, 523059, Guangdong, China
| | - Shaohui Su
- Department of Cardiology, Dongguan People's Hospital, Southern Medical University, Dongguan, 523059, Guangdong, China
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17
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Andersen NG, Mowinckel MC, Sunde K, Sandset PM, Beitland S. Utility of coagulation analyses to assess thromboprophylaxis with dalteparin in intensive care unit patients. Acta Anaesthesiol Scand 2021; 65:489-498. [PMID: 33205407 DOI: 10.1111/aas.13748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/19/2020] [Accepted: 11/08/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the utility of coagulation analyses to assess thromboprophylaxis with dalteparin in intensive care unit (ICU) patients. METHODS Prospective observational study of ICU patients receiving dalteparin prophylaxis at Oslo University Hospital in Norway. Trough and peak antithrombin, protein C, anti-factor Xa activity (aFXa), d-dimer, thromboelastography, calibrated automated thrombogram and microparticles were analysed. Levels were compared in patients with and without venous thromboembolism (VTE), major bleeding, acute kidney injury (AKI) with use of renal replacement therapy (RRT) and variable dalteparin dose. RESULTS Among 50 included patients (76% male, mean age 62 years) five (10%) developed VTE and eight (16%) major bleeding. Median through aFXa level was 0.03 (0.02-0.05) IU/mL, and 48 (96%) of patients were within and two (4%) above target range. Peak aFXa level was 0.21 (0.13-0.29) IU/mL, the number of patients below, within and above prophylactic range were 21 (42%), 25 (50%) and four (8%). Peak aFXa levels were similar in patients with and without VTE (0.18 vs 0.21 IU/L, P = .72), major bleeding (0.22 vs 0.21 IU/mL, P = .38) and AKI with RRT (0.18 vs 0.24, P = .13), but lower in patients receiving dalteparin 5000 IU od compared to 7500 IU od (0.19 vs 0.30 IU/mL, P < .01). CONCLUSIONS Intensive care unit patients receiving dalteparin prophylaxis had half of patients within prophylactic peak aFXa target range. Peak aFXa levels was affected by administered dalteparin dose, but not presence of VTE, major bleeding or AKI with RRT.
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Affiliation(s)
| | - Marie-Christine Mowinckel
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Kjetil Sunde
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Universitetet i Oslo, Oslo, Norway
| | - Per Morten Sandset
- Department of Haematology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Universitetet i Oslo, Oslo, Norway
| | - Sigrid Beitland
- Renal Research Group Ullevål, Faculty of Medicine, University of Oslo, Oslo, Norway
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18
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Gillespie L, Khan RZ, Stillson JE, Bunch CM, Shariff FS, Speybroeck J, Grisoli A, Schmidt MW, Phyu H, Jablonski J, Wells B, Fulkerson DH, Oancea L, Leiser A, Walsh M. Impact of a clinical pharmacist on ultrasound-guided venous thromboembolism screening in hospitalized COVID-19 patients: a pilot prospective study. J Pharm Health Care Sci 2021; 7:19. [PMID: 33795030 PMCID: PMC8015749 DOI: 10.1186/s40780-021-00201-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 03/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background The recognition, prevention and treatment of venous thromboembolism (VTE) remains a major challenge in the face of the recent COVID-19 pandemic which has been associated with significant cardiovascular, renal, respiratory and hematologic complications related to hypercoagulability. There has been little literature thus far on the utility of screening ultrasound and the role of the clinical pharmacist in treating these patients. Methods We present a prospective pilot program of thirty-one consecutive COVID-19 patients who were provided four extremity screening ultrasounds for VTE on admission. This was coordinated by a clinical pharmacist as part of a multidisciplinary approach. Quantitative and qualitative data were recorded with the goal of describing the utility of the clinical pharmacist in ultrasound screening. Data collected include demographics, information on clinical symptoms or signs at presentation, and laboratory and radiologic results during the hospitalization from each individual electronic medical record. Results Nine of the thirty-one patients presented with VTE. Of the nine patients, there were twenty-two total clotted vessels, all of which were asymptomatic. The clinical pharmacist, as the coordinator for a multidisciplinary COVID-19 associated coagulopathy management team, drafted a screening and treatment protocol for anticoagulation prophylaxis and therapy of VTE after ultrasound findings. Conclusion VTE screening of hospitalized COVID-19 patients reveals a significant number of asymptomatic VTEs and justifies diagnostic, prophylactic, and treatment measures coordinated by a clinical pharmacist.
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Affiliation(s)
- Laura Gillespie
- Department of Quality and Performance Improvement, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Rashid Z Khan
- Department of Hematology, Michiana Hematology Oncology, Mishawaka, IN, USA
| | - John E Stillson
- South Bend Campus, Indiana University School of Medicine, South Bend, IN, USA
| | - Connor M Bunch
- South Bend Campus, Indiana University School of Medicine, South Bend, IN, USA
| | | | - Jacob Speybroeck
- South Bend Campus, Indiana University School of Medicine, South Bend, IN, USA
| | - Anne Grisoli
- South Bend Campus, Indiana University School of Medicine, South Bend, IN, USA
| | | | - Htay Phyu
- Department of Infectious Diseases, St. Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Jason Jablonski
- Department of Quality and Performance Improvement, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Byars Wells
- Department of Emergency of Medicine, St. Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Daniel H Fulkerson
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Lyndsay Oancea
- Department of Radiology, St. Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Abraham Leiser
- South Bend Campus, Indiana University School of Medicine, South Bend, IN, USA
| | - Mark Walsh
- Department of Emergency of Medicine, St. Joseph Regional Medical Center, Mishawaka, IN, USA. .,Department of Internal Medicine, St. Joseph Regional Medical Center, 5215 Holy Cross Pkwy, Mishawaka, IN, 46545, USA.
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19
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Yi G, Deane AM, Ankravs M, Sharrock L, Anstey J, Abdelhamid YA. A fixed dose approach to thrombosis chemoprophylaxis may be inadequate in heavier critically ill patients. CRIT CARE RESUSC 2021; 23:94-102. [PMID: 38046388 PMCID: PMC10692573 DOI: 10.51893/2021.1.oa9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Overweight patients are at greater risk of venous thromboembolism. We aimed to describe prescribing patterns of thrombosis chemoprophylaxis in critically ill patients weighing ≥ 100 kg and quantify the effectiveness of these regimens using the surrogate biomarker of plasma anti-Xa level. Design, setting and patients: A prospective single-centre cohort study was conducted over a 6-month period. Patients weighing ≥ 100 kg who were prescribed enoxaparin for chemoprophylaxis and expected to remain in the intensive care unit for > 48 hours were eligible. Anti-Xa levels were measured once a patient had received at least three consecutive doses of enoxaparin. Peak levels were measured 4-6 hours after the third dose and trough levels were measured before the fourth dose. Anti-Xa levels were compared with established target ranges for peak and trough anti-Xa levels (0.2-0.5 IU/mL and > 0.1 IU/mL, respectively). Results: Eighty-eight patients met the eligibility criteria, and anti-Xa levels for 42 patients were obtained. Fixed dose chemoprophylaxis approaches varied considerably, with 40 mg once daily (54/88 [61%]) and 40 mg twice daily (20/88 [23%]) being the most frequently prescribed regimens. No patient had a peak anti-Xa level > 0.5 IU/mL. When comparing 40 mg once daily versus twice daily, the once daily regimen had lower median trough levels (0.01 IU/mL [interquartile range (IQR), 0.00-0.04] v 0.09 IU/mL [IQR, 0.05-0.13]; P < 0.001) and greater proportions of patients with levels below the established range (< 0.1 IU/mL) (15/16 [95%] v 7/14 [50%]; P = 0.002) and levels that were undetectable (0.00 IU/mL) (8/16 [50%] v 1/14 [7%]; P = 0.01). Conclusions: At a single centre, thrombosis chemoprophylaxis prescribing patterns for heavier critically ill patients varied considerably. Current fixed dose approaches may be inadequate in this cohort.
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Affiliation(s)
- George Yi
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Adam M. Deane
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Critical Care, Melbourne, VIC, Australia
| | - Melissa Ankravs
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Critical Care, Melbourne, VIC, Australia
- Pharmacy Department, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Lucy Sharrock
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Pharmacy Department, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - James Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Critical Care, Melbourne, VIC, Australia
| | - Yasmine Ali Abdelhamid
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Critical Care, Melbourne, VIC, Australia
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20
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The Role of TEG Analysis in Patients with COVID-19-Associated Coagulopathy: A Systematic Review. Diagnostics (Basel) 2021; 11:diagnostics11020172. [PMID: 33530346 PMCID: PMC7911186 DOI: 10.3390/diagnostics11020172] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/20/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19)-associated coagulopathy (CAC), characterized by hypercoagulability and an increased risk of thrombotic complications, is an important consideration in the management of patients with COVID-19. As COVID-19 is a new disease, no standard of care for the diagnosis or management of its associated coagulopathy is yet established. Whole blood viscoelastic tests, such as thromboelastography (TEG® hemostasis analyzer), analyze whole blood to provide a complete overview of the coagulation status. We conducted a systematic review of thromboelastography for management of patients with COVID-19, using MEDLINE (PubMed) and Cochrane databases. TEG® parameter measurements and clinical outcomes data were extracted for analysis. Our review found 15 publications, with overall results showing thromboelastography can identify and assess a hypercoagulable state in patients with COVID-19. Furthermore, utilization of thromboelastography in this patient population was shown to predict thrombotic complications. The benefits of thromboelastography presented here, in addition to advantages compared with laboratory coagulation tests, position thromboelastography as an important opportunity for optimizing diagnosis of CAC and improving patient management in COVID-19. Given that the benefits of thromboelastography have already been demonstrated in several other clinical applications, we anticipate that clinical data from future studies in patients with COVID-19 will further elucidate the optimal use of thromboelastography in this patient population.
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21
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Słomka A, Kowalewski M, Żekanowska E. Hemostasis in Coronavirus Disease 2019-Lesson from Viscoelastic Methods: A Systematic Review. Thromb Haemost 2021; 121:1181-1192. [PMID: 33401332 DOI: 10.1055/a-1346-3178] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hemostatic unbalance is often observed in patients with coronavirus disease 2019 (COVID-19), and patients with severe disease are at high risk of developing thromboembolic complications. Viscoelastic methods (VEMs), including thrombelastography (TEG) and thromboelastometry (TEM), provide data on the nature of hemostatic disturbance. In this systematic review, we assessed the performance of TEG and TEM in the assessment of blood coagulation and fibrinolysis in patients with COVID-19. PubMed, Scopus, Web of Science Core Collection, medRxiv, and bioRxiv were systematically searched for clinical studies evaluating TEG and/or TEM variables in COVID-19 individuals. Ten studies, with a total of 389 COVID-19 patients, were included, and VEMs were performed in 292 of these patients. Most patients (90%) presented severe COVID-19 and required mechanical ventilation. TEG and TEM variables showed that these patients displayed hypercoagulability and fibrinolysis shutdown, despite the use of appropriate thromboprophylaxis. However, the mechanism underlying these phenomena and their clinical significance in COVID-19 patients who developed thrombosis are still not clear. Further studies are warranted if VEMs might help to identify those at highest risk of thrombotic events and who therefore may derive the greatest benefit from antithrombotic therapy.
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Affiliation(s)
- Artur Słomka
- Department of Pathophysiology, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum Bydgoszcz, Poland
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland.,Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiothoracic Research Centre, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum Bydgoszcz, Poland
| | - Ewa Żekanowska
- Department of Pathophysiology, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum Bydgoszcz, Poland
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22
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Hardy M, Lecompte T, Douxfils J, Lessire S, Dogné JM, Chatelain B, Testa S, Gouin-Thibault I, Gruel Y, Medcalf RL, ten Cate H, Lippi G, Mullier F. Management of the thrombotic risk associated with COVID-19: guidance for the hemostasis laboratory. Thromb J 2020; 18:17. [PMID: 32922211 PMCID: PMC7474970 DOI: 10.1186/s12959-020-00230-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/21/2020] [Indexed: 02/07/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is associated with extreme inflammatory response, disordered hemostasis and high thrombotic risk. A high incidence of thromboembolic events has been reported despite thromboprophylaxis, raising the question of a more effective anticoagulation. First-line hemostasis tests such as activated partial thromboplastin time, prothrombin time, fibrinogen and D-dimers are proposed for assessing thrombotic risk and monitoring hemostasis, but are vulnerable to many drawbacks affecting their reliability and clinical relevance. Specialized hemostasis-related tests (soluble fibrin complexes, tests assessing fibrinolytic capacity, viscoelastic tests, thrombin generation) may have an interest to assess the thrombotic risk associated with COVID-19. Another challenge for the hemostasis laboratory is the monitoring of heparin treatment, especially unfractionated heparin in the setting of an extreme inflammatory response. This review aimed at evaluating the role of hemostasis tests in the management of COVID-19 and discussing their main limitations.
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Affiliation(s)
- M. Hardy
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Hematology Laboratory, Yvoir, Belgium
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Anesthesiology Department, Yvoir, Belgium
| | - T. Lecompte
- Département de Médecine, Hôpitaux Universitaires de Genève, service d’angiologie et d’hémostase et Faculté de Médecine Geneva Platelet Group (GpG), Université de Genève, Geneva, Suisse Switzerland
| | - J. Douxfils
- Pharmacy Department, University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur, Belgium
- Qualiblood s.a, Namur, Belgium
| | - S. Lessire
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Anesthesiology Department, Yvoir, Belgium
| | - J. M. Dogné
- Pharmacy Department, University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur, Belgium
| | - B. Chatelain
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Hematology Laboratory, Yvoir, Belgium
| | - S. Testa
- Haemostasis and Thrombosis Center, Cremona Hospital, Cremona, Italy
| | - I. Gouin-Thibault
- Département d’Hématologie Biologique, INSERM, CIC 1414 (Centre d’Investigation Clinique de Rennes), Université de Rennes, CHU de Rennes, Rennes, France
| | - Y. Gruel
- Laboratoire d’Hématologie-Hémostase, CHRU de Tours, Hôpital Trousseau, Tours, France
| | - R. L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria Australia
| | - H. ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
| | - G. Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - F. Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Hematology Laboratory, Yvoir, Belgium
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23
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Yuriditsky E, Horowitz JM, Merchan C, Ahuja T, Brosnahan SB, McVoy L, Berger JS. Thromboelastography Profiles of Critically Ill Patients With Coronavirus Disease 2019. Crit Care Med 2020; 48:1319-1326. [PMID: 32618696 PMCID: PMC7314320 DOI: 10.1097/ccm.0000000000004471] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The rate of thromboembolic events among patients with coronavirus disease 2019 is high; however, there is no robust method to identify those at greatest risk. We reviewed thromboelastography studies in critically ill patients with coronavirus disease 2019 to characterize their coagulation states. DESIGN Retrospective. SETTING Tertiary ICU in New York City. PATIENTS Sixty-four patients with coronavirus disease 2019 admitted to the ICU with thromboelastography performed. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Fifty percent of patients had a clotting index in the hypercoagulable range (clotting index > 3) (median 3.05). Reaction time and K values were below the lower limit of normal in 43.8% of the population consistent with a hypercoagulable profile. The median α angle and maximum amplitude (75.8° and 72.8 mm, respectively) were in the hypercoagulable range. The α angle was above reference range in 70.3% of patients indicative of rapid clot formation. Maximum amplitude, a factor of fibrinogen and platelet count and function, and a measure of clot strength was above reference range in 60.1% of patients. Thirty-one percent had thromboembolic events; thromboelastography parameters did not correlate with events in our cohort. Those with D-dimer values greater than 2,000 were more likely to have shorter reaction times compared with those with D-dimer levels less than or equal to 2,000 (4.8 vs 5.6 min; p = 0.001). CONCLUSIONS A large proportion of critically ill patients with coronavirus disease 2019 have hypercoagulable thromboelastography profiles with additional derangements related to fibrinogen and platelet function. As the majority of patients have an elevated thromboelastography maximum amplitude, a follow-up study evaluating platelet aggregation would be instructive.
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Affiliation(s)
- Eugene Yuriditsky
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
| | - James M Horowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
| | | | - Tania Ahuja
- Department of Pharmacy, NYU Langone Health, New York, NY
| | - Shari B Brosnahan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Langone Health, New York, NY
| | - Lauren McVoy
- Department of Pathology, NYU Langone Health, New York, NY
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
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Incidence of Antithrombin Deficiency and Anti-Cardiolipin Antibodies After Severe Traumatic Brain Injury: A Prospective Cohort Study. Neurocrit Care 2020; 34:227-235. [PMID: 32557110 DOI: 10.1007/s12028-020-01026-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Animal studies suggested that cerebral mitochondrial cardiolipin phospholipids were released after severe traumatic brain injury (TBI), contributing to the pathogenesis of thromboembolism. OBJECTIVES To determine the incidence of anti-cardiolipin antibodies after severe TBI and whether this was related to the severity of TBI and development of venous thromboembolism. METHODS Serial anti-cardiolipin antibodies, antithrombin levels, viscoelastic testing, and coagulation parameters were measured on admission, day-1, and between day-5 and day-7 in patients with severe TBI requiring intracranial pressure monitoring. RESULTS Of the 40 patients included (85% male and median age 42 years), 7 (18%) had a raised Ig-G or Ig-M anti-cardiolipin antibody titer after TBI. Antithrombin levels were below the normal level-especially on day-0 and day-1-in 15 patients (38%), and 14 patients (38%) developed an increase in maximum clot firmness on the viscoelastic test in conjunction with elevations in fibrinogen concentration and platelet count. Four patients (10%) developed deep vein thrombosis, and 10 patients (25%) died, both of which were not significantly related to the presence of anti-cardiolipin antibodies (P = 0.619 and P = 0.638, respectively). CONCLUSIONS A reduction in antithrombin level and development of anti-cardiolipin antibodies were not rare immediately after severe TBI; these abnormalities were followed by an increase in in vitro clot strength due to elevations in fibrinogen concentration and platelet count. The quantitative relationships between the development of anti-cardiolipin antibodies and severity of TBI or clinical thromboembolic events deserve further investigation.
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25
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Wright FL, Vogler TO, Moore EE, Moore HB, Wohlauer MV, Urban S, Nydam TL, Moore PK, McIntyre RC. Fibrinolysis Shutdown Correlation with Thromboembolic Events in Severe COVID-19 Infection. J Am Coll Surg 2020; 231:193-203.e1. [PMID: 32422349 PMCID: PMC7227511 DOI: 10.1016/j.jamcollsurg.2020.05.007] [Citation(s) in RCA: 281] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 01/08/2023]
Abstract
Background COVID-19 predisposes patients to a prothrombotic state with demonstrated microvascular involvement. The degree of hypercoagulability appears to correlate with outcomes; however, optimal criteria to assess for the highest-risk patients for thrombotic events remain unclear; we hypothesized that deranged thromboelastography measurements of coagulation would correlate with thromboembolic events. Study Design Patients admitted to an ICU with COVID-19 diagnoses who had thromboelastography analyses performed were studied. Conventional coagulation assays, d-dimer levels, and viscoelastic measurements were analyzed using a receiver operating characteristic curve to predict thromboembolic outcomes and new-onset renal failure. Results Forty-four patients with COVID-19 were included in the analysis. Derangements in coagulation laboratory values, including elevated d-dimer, fibrinogen, prothrombin time, and partial thromboplastin time, were confirmed; viscoelastic measurements showed an elevated maximum amplitude and low lysis of clot at 30 minutes. A complete lack of lysis of clot at 30 minutes was seen in 57% of patients and predicted venous thromboembolic events with an area under the receiver operating characteristic curve of 0.742 (p = 0.021). A d-dimer cutoff of 2,600 ng/mL predicted need for dialysis with an area under the receiver operating characteristic curve of 0.779 (p = 0.005). Overall, patients with no lysis of clot at 30 minutes and a d-dimer > 2,600 ng/mL had a venous thromboembolic event rate of 50% compared with 0% for patients with neither risk factor (p = 0.008), and had a hemodialysis rate of 80% compared with 14% (p = 0.004). Conclusions Fibrinolysis shutdown, as evidenced by elevated d-dimer and complete failure of clot lysis at 30 minutes on thromboelastography predicts thromboembolic events and need for hemodialysis in critically ill patients with COVID-19. Additional clinical trials are required to ascertain the need for early therapeutic anticoagulation or fibrinolytic therapy to address this state of fibrinolysis shutdown.
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Affiliation(s)
| | | | - Ernest E Moore
- Departments of Surgery; Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO
| | | | | | - Shane Urban
- University of Colorado Anschutz Medical Campus, UCHealth, University of Colorado Hospital, Aurora
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26
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In Search of Answers and Technology to Better Identify the Bleeding and the Hypercoagulable Patient Phenotype-The Need for Improved Assessment of Deranged Coagulation Beyond Our Current Coagulation Tests. Crit Care Med 2020; 47:876-877. [PMID: 31095021 DOI: 10.1097/ccm.0000000000003754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Thromboelastography Predicts Thromboembolism in Critically Ill Coagulopathic Patients. Crit Care Med 2019; 47:e853. [DOI: 10.1097/ccm.0000000000003929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Vena Cava filters in severely-injured patients: One size does not fit all. Anaesth Crit Care Pain Med 2019; 38:305-307. [DOI: 10.1016/j.accpm.2019.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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