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Jogerst KM. One Size Fits None: The Difficult Dilemma of Perioperative Anticoagulation Management. Mayo Clin Proc 2024; 99:1024-1026. [PMID: 38960490 DOI: 10.1016/j.mayocp.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 05/22/2024] [Indexed: 07/05/2024]
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Liu Q, Guo S, Wang N, Wang K, Mo S, Li X, Zhang Y, He H, Wang S, Wu J. Model based on single-nucleotide polymorphism to discriminate aspirin resistance patients. Stroke Vasc Neurol 2024; 9:212-220. [PMID: 37586776 PMCID: PMC11221311 DOI: 10.1136/svn-2022-002228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/30/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Aspirin is widely used for preventing ischaemic events. About 20%-40% of patients have aspirin resistance (ASR), which prevents them from benefiting from aspirin medication. This study aimed to develop and validate a model based on single-nucleotide polymorphism (SNP) to distinguish ASR patients. METHODS We included patients with spontaneous intracerebral haemorrhage and continuing antiplatelet therapy from a multicentre, prospective cohort study as the derivation cohort. Thromboelastography (inhibition of arachidonic acid channel<50%) was used to identify ASR. Genotyping was performed to identify the ASR-related SNP. Based on the result of the logistic analysis, the aspirin resistance in the Chinese population score (ASR-CN score) was established, and its accuracy was evaluated using the area under the curve (AUC). Patients receiving dual antiplatelet therapy for unruptured intracranial aneurysm embolism were prospectively included in the validation cohort. After embolism, 30-day ischaemic events, including ischaemic stroke, new or more frequent transient ischaemic attack, stent thrombosis and cerebrovascular death, were recorded. RESULTS The derivation cohort included 212 patients (155 male patients and the median age as 59). 87 (41.0%) individuals were identified with ASR. The multivariate logistic analysis demonstrated six SNPs of GP1BA, TBXA2R, PTGS2 and NOS3 as risk factors related to ASR. The ASR-CN score integrating these SNPs performed well to discriminate ASR patients from non-ASR patients (AUC as 0.77). Based on the validation cohort of 372 patients receiving antiplatelet therapy after embolism (including 130 ASR patients), the ASR-CN score continued to distinguish ASR patients with good accuracy (AUC as 0.80). Patients with high a ASR-CN score were more likely to suffer from 30-day ischaemic events after embolism (OR, 1.28; 95% CI, 1.10 to 1.50; p=0.002). CONCLUSION GP1BA, TBXA2R, PTGS2 and NOS3 were SNPs related to ASR. The ASR-CN score is an effective tool to discriminate ASR patients, which may guide antiplatelet therapy. CLINICAL TRIAL REGISTRATION Surgical Treatments of Antiplatelet Intracerebral Hemorrhage cohort (unique identifier: ChiCTR1900024406, http://www.chictr.org.cn/edit.aspx?pid=40640&htm=4).
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Affiliation(s)
- Qingyuan Liu
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Shuaiwei Guo
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Nuochuan Wang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Beijing, China
| | - Kaiwen Wang
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Shaohua Mo
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xiong Li
- Department of Neurosurgery, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
| | - Yanan Zhang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Beijing, China
| | - Hongwei He
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
- Beijing Neurosurgical institution, Capital Medical University, Beijing, China
| | - Shuo Wang
- Beijing Neurosurgical institution, Capital Medical University, Beijing, China
| | - Jun Wu
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
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Yamamoto R, Maeshima K, Funabiki T, Eastridge BJ, Cestero RF, Sasaki J. Immediate Angiography and Decreased In-Hospital Mortality of Adult Trauma Patients: A Nationwide Study. Cardiovasc Intervent Radiol 2024; 47:472-480. [PMID: 38332119 DOI: 10.1007/s00270-024-03664-6] [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: 11/23/2023] [Accepted: 01/11/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE This study aimed to elucidate whether immediate angiography within 30 min is associated with lower in-hospital mortality compared with non-immediate angiography. MATERIALS AND METHODS We conducted a retrospective cohort study using a nationwide trauma databank (2019-2020). Adult trauma patients who underwent emergency angiography within 12 h after hospital arrival were included. Patients who underwent surgery before angiography were excluded. Immediate angiography was defined as one performed within 30 min after arrival (door-to-angio time ≤ 30 min). In-hospital mortality and non-operative management (NOM) failure were compared between patients with immediate and non-immediate angiography. Inverse probability weighting with propensity scores was conducted to adjust patient demographics, injury mechanism and severity, vital signs on hospital arrival, and resuscitative procedures. A restricted cubic spline curve was drawn to reveal survival benefits by door-to-angio time. RESULTS Among 1,455 patients eligible for this study, 92 underwent immediate angiography. Angiography ≤ 30 min was associated with decreased in-hospital mortality (5.0% vs 11.1%; adjusted odds ratio [OR], 0.42 [95% CI, 0.31-0.56]; p < 0.001), as well as lower frequency of NOM failure: thoracotomy and laparotomy after angiography (0.8% vs. 1.8%; OR, 0.44 [0.22-0.89] and 2.6% vs. 6.5%; OR, 0.38 [0.26-0.56], respectively). The spline curve showed a linear association between increasing mortality and prolonged door-to-angio time in the initial 100 min after arrival. CONCLUSION In trauma patients, immediate angiography ≤ 30 min was associated with lower in-hospital mortality and fewer NOM failures. LEVEL OF EVIDENCE Level 3b, non randomized controlled cohort/follow up study.
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Affiliation(s)
- Ryo Yamamoto
- Trauma Service/Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan.
| | - Katsuya Maeshima
- Trauma Service/Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Tomohiro Funabiki
- Department of Emergency Medicine, Fujita Health University Hospital, 1-98 Dengakugakubo, Kutsukake-Cho, Toyoake, Aichi, 470-1192, Japan
| | - Brian J Eastridge
- Department of Surgery, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA
| | - Ramon F Cestero
- Department of Surgery, UT Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA
| | - Junichi Sasaki
- Trauma Service/Department of Emergency and Critical Care Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
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Maier CL, Brohi K, Curry N, Juffermans NP, Mora Miquel L, Neal MD, Shaz BH, Vlaar APJ, Helms J. Contemporary management of major haemorrhage in critical care. Intensive Care Med 2024; 50:319-331. [PMID: 38189930 DOI: 10.1007/s00134-023-07303-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024]
Abstract
Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU).
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Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, USA
| | - Karim Brohi
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Clinical and Laboratory Sciences, Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Nicole P Juffermans
- Department of Intensive Care and Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lidia Mora Miquel
- Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d'Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de La Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beth H Shaz
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | | | - Julie Helms
- Service de Médecine Intensive-Réanimation, Department of Intensive Care, Nouvel Hôpital Civil, Université de Strasbourg (UNISTRA), 1, Place de L'Hôpital, 67091, Strasbourg Cedex, France.
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Crochemore T, Görlinger K, Lance MD. Early Goal-Directed Hemostatic Therapy for Severe Acute Bleeding Management in the Intensive Care Unit: A Narrative Review. Anesth Analg 2024; 138:499-513. [PMID: 37977195 PMCID: PMC10852045 DOI: 10.1213/ane.0000000000006756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 11/19/2023]
Abstract
This is a narrative review of the published evidence for bleeding management in critically ill patients in different clinical settings in the intensive care unit (ICU). We aimed to describe "The Ten Steps" approach to early goal-directed hemostatic therapy (EGDHT) using point-of-care testing (POCT), coagulation factor concentrates, and hemostatic drugs, according to the individual needs of each patient. We searched National Library of Medicine, MEDLINE for publications relevant to management of critical ill bleeding patients in different settings in the ICU. Bibliographies of included articles were also searched to identify additional relevant studies. English-language systematic reviews, meta-analyses, randomized trials, observational studies, and case reports were reviewed. Data related to study methodology, patient population, bleeding management strategy, and clinical outcomes were qualitatively evaluated. According to systematic reviews and meta-analyses, EGDHT guided by viscoelastic testing (VET) has been associated with a reduction in transfusion utilization, improved morbidity and outcome in patients with active bleeding. Furthermore, literature data showed an increased risk of severe adverse events and poor clinical outcomes with inappropriate prophylactic uses of blood components to correct altered conventional coagulation tests (CCTs). Finally, prospective, randomized, controlled trials point to the role of goal-directed fibrinogen substitution to reduce bleeding and the amount of red blood cell (RBC) transfusion with the potential to decrease mortality. In conclusion, severe acute bleeding management in the ICU is still a major challenge for intensive care physicians. The organized and sequential approach to the bleeding patient, guided by POCT allows for rapid and effective bleeding control, through the rational use of blood components and hemostatic drugs, since VET can identify specific coagulation disorders in real time, guiding hemostatic therapy with coagulation factor concentrates and hemostatic drugs with individual goals.
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Affiliation(s)
- Tomaz Crochemore
- From the Department of Critical Care, Hospital Vila Nova Star, São Paulo, Brazil
- Department of Critical Care, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Werfen LATAM, São Paulo, Brazil
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
- TEM Innovations GmbH/Werfen PBM, Munich, Germany
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Heo Y, Chang SW, Lee SW, Ma DS, Kim DH. Hemostatic effect of fibrinogen concentrate on traumatic massive hemorrhage: a propensity score matching study. Trauma Surg Acute Care Open 2024; 9:e001271. [PMID: 38298819 PMCID: PMC10828838 DOI: 10.1136/tsaco-2023-001271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
Background Fibrinogen concentrate (FC) can be administered during massive transfusions to manage trauma-induced coagulopathy. However, its effectiveness in survival remains inconclusive due to scarce high-level evidence. This study aimed to investigate the hemostatic effects of FC regarding mortality in massive hemorrhage caused by trauma. Methods This retrospective study analyzed 839 patients who received massive transfusions (red blood cells (RBCs) ≥5 units in 4 hours or ≥10 units in 24 hours) at a level I trauma center between 2015 and 2022. Patients who were transferred to other hospitals or were deceased upon arrival, suffered or died from severe brain injury, and were aged 15 years or less were excluded (n=334). 1:2 propensity score matching was performed to compare the 'FC (+)' group who had received FC in 24 hours (n=68) with those who had not ('FC (-)', n=437). The primary outcome was mortality, and the secondary outcomes included transfusion volume. Results The variables for matching included vital signs, injury characteristics, prehospital time, implementation of resuscitative endovascular balloon occlusion of the aorta, and blood gas analysis results. The administration of FC did not significantly reduce or predict mortality (in-hospital, 24 hours, 48 hours, or 7 days). The FC (-) group received more units of RBC (25.69 units vs. 16.71 units, p<0.001, standardized mean difference [SMD] 0.595), fresh frozen plasma (16.79 units vs. 12.91 units, p=0.023, SMD 0.321), and platelets (8.76 units vs. 5.46 units, p=0.002, SMD 0.446) than the FC (+) group. Conclusion The use of FC did not show survival benefits but reduced transfusion requirements in traumatic massive hemorrhages, highlighting a need for future investigations. In the future, individualized goal-directed transfusion with FC may play a significant role in treating massive bleeding. Level of evidence IV, retrospective study having more than one negative criterion.
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Affiliation(s)
- Yoonjung Heo
- Division of Surgery, Department of Medicine, Dankook University Graduate School, Cheonan, Chungnam, Korea (the Republic of)
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Chungnam, Korea (the Republic of)
| | - Sung Wook Chang
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Chungnam, Korea (the Republic of)
| | - Seok Won Lee
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Chungnam, Korea (the Republic of)
| | - Dae Sung Ma
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Chungnam, Korea (the Republic of)
| | - Dong Hun Kim
- Division of Trauma Surgery, Department of Surgery, Dankook University College of Medicine, Cheonan, Chungnam, Korea (the Republic of)
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Gruneberg D, Hofer S, Schöchl H, Zipperle J, Oberladstätter D, Decker SO, Von der Forst M, Tourelle KM, Dietrich M, Weigand MA, Schmitt FCF. Comparison of Two Viscoelastic Testing Devices in a Parturient Population. J Clin Med 2024; 13:692. [PMID: 38337386 PMCID: PMC10856714 DOI: 10.3390/jcm13030692] [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: 12/23/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Viscoelastic hemostatic assays (VHAs) have become an integral diagnostic tool in guiding hemostatic therapy, offering new opportunities in personalized hemostatic resuscitation. This study aims to assess the interchangeability of ClotPro® and ROTEM® delta in the unique context of parturient women. Methods: Blood samples from 217 parturient women were collected at three timepoints. A total of 631 data sets were eligible for our final analysis. The clotting times were analyzed via extrinsic and intrinsic assays, and the clot firmness parameters A5, A10, and MCF were analyzed via extrinsic, intrinsic, and fibrin polymerization assays. In parallel, the standard laboratory coagulation statuses were obtained. Device comparison was assessed using regression and Bland-Altman plots. The best cutoff calculations were used to determine the VHA values corresponding to the established standard laboratory cutoffs. Results: The clotting times in the extrinsic and intrinsic assays showed notable differences between the devices, while the extrinsic and intrinsic clot firmness results demonstrated interchangeability. The fibrinogen assays revealed higher values in ClotPro® compared to ROTEM®. An ROC analysis identified VHA parameters with high predictive values for coagulopathy exclusion and yet low specificity. Conclusions: In the obstetric setting, the ROTEM® and ClotPro® parameters demonstrate a significant variability. Device- and indication-specific transfusion algorithms are essential for the accurate interpretation of measurements and adequate hemostatic therapy.
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Affiliation(s)
- Daniel Gruneberg
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Stefan Hofer
- Department of Anesthesiology, Kaiserslautern Westpfalz Hospital, 67655 Kaiserslautern, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, 1200 Vienna, Austria
| | - Johannes Zipperle
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, 1200 Vienna, Austria
| | - Daniel Oberladstätter
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, 1200 Vienna, Austria
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria
| | - Sebastian O. Decker
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Maik Von der Forst
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Kevin Michel Tourelle
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Maximilian Dietrich
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Markus A. Weigand
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
| | - Felix C. F. Schmitt
- Department of Anesthesiology, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (D.G.)
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Zipperle J, Schmitt FCF, Schöchl H. Point-of-care, goal-directed management of bleeding in trauma patients. Curr Opin Crit Care 2023; 29:702-712. [PMID: 37861185 DOI: 10.1097/mcc.0000000000001107] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to consider the clinical value of point-of-care (POC) testing in coagulopathic trauma patients with traumatic brain injury (TBI) and trauma-induced coagulopathy (TIC). RECENT FINDINGS Patients suffering from severe TBI or TIC are at risk of developing pronounced haemostatic disorders. Standard coagulation tests (SCTs) are insufficient to reflect the complexity of these coagulopathies. Recent evidence has shown that viscoelastic tests (VETs) identify haemostatic disorders more rapidly and in more detail than SCTs. Moreover, VET results can guide coagulation therapy, allowing individualised treatment, which decreases transfusion requirements. However, the impact of VET on mortality remains uncertain. In contrast to VETs, the clinical impact of POC platelet function testing is still unproven. SUMMARY POC SCTs are not able to characterise the complexity of trauma-associated coagulopathy. VETs provide a rapid estimation of underlying haemostatic disorders, thereby providing guidance for haemostatic therapy, which impacts allogenic blood transfusion requirements. The value of POC platelet function testing to identify platelet dysfunction and guide platelet transfusion is still uncertain.
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Affiliation(s)
- Johannes Zipperle
- Ludwig Boltzmann Institute for Traumatology, the Research Centre in Cooperation with AUVA, Vienna
| | - Felix C F Schmitt
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, the Research Centre in Cooperation with AUVA, Vienna
- Paracelsus Medical University, Salzburg, Austria
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Leal-Noval SR, Rincón-Ferrari MD. A strategy to treat coagulopathy in patients with massive hemorrhage. Med Intensiva 2023; 47:543-546. [PMID: 37156720 DOI: 10.1016/j.medine.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/09/2023] [Indexed: 05/10/2023]
Affiliation(s)
- Santiago R Leal-Noval
- Critical Care Division, University Hospital 'Virgen del Rocío', Seville, Spain; Critical Care Division, Hospital 'Virgen de Fátima', Spain.
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Salehi M, Bola R, de Jong N, Shih AW, Garraway N, Dawe P. Guided blood transfusion of trauma patients with rotational thromboelastometry: a single-center cohort study. World J Emerg Surg 2023; 18:40. [PMID: 37393239 DOI: 10.1186/s13017-023-00508-5] [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: 05/31/2022] [Accepted: 06/20/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Rotational thromboelastometry (ROTEM) is a blood test used to measure in vitro clot strength as a surrogate for a patient's ability to form clots in vivo. This provides information about induction, formation, and clot lysis, allowing goal-directed transfusion therapy for specific hemostatic needs. We sought to evaluate the effect of ROTEM-guided transfusion on blood product usage and in-hospital mortality among patients with a traumatic injury. METHODS This was a single-center observational cohort analysis of emergency department patients in a Level 1 trauma center. We compared blood usage in trauma patients in whom ratio-based massive hemorrhage protocols were activated in the twelve months before the introduction of ROTEM (pre-ROTEM group) to the twelve months following the introduction of ROTEM (ROTEM-period group). ROTEM was implemented in this center in November 2016. The ROTEM device allowed clinicians to make real-time decisions about blood product therapy in resuscitation for trauma. RESULTS The pre-ROTEM group contained 21 patients. Forty-three patients were included from the ROTEM-period, of whom 35 patients received ROTEM-guided resuscitation (81% compliance). The use of fibrinogen concentrate was significantly higher in the ROTEM-period group (pre-ROTEM mean 0.2 vs. ROTEM-period mean 0.8; p = 0.006). There was no significant difference in the number of units of red blood cells, platelets, cryoprecipitate, or fresh frozen plasma transfused between these groups. There was no significant difference in the mortality rate between the pre-ROTEM and ROTEM-period groups (33% vs. 19%; p = 0.22). CONCLUSIONS The introduction of ROTEM-guided transfusion at this institution was associated with increased fibrinogen usage, but this did not impact mortality rates. There was no difference in the administration of red blood cell, fresh frozen plasma, platelet, and cryoprecipitate. Future research should focus on increased ROTEM compliance and optimizing ROTEM-guided transfusion to prevent blood product overuse among trauma patients.
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Affiliation(s)
- Mina Salehi
- Division of General Surgery, Trauma and Acute Care Surgery, Vancouver General Hospital, University of British Columbia, Jim Pattison Pavilion, 855 W 12th Ave, Vancouver, BC, V5Z 1M9, Canada.
| | - Rajan Bola
- Division of General Surgery, Trauma and Acute Care Surgery, Vancouver General Hospital, University of British Columbia, Jim Pattison Pavilion, 855 W 12th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Nenke de Jong
- Division of General Surgery, Trauma and Acute Care Surgery, Vancouver General Hospital, University of British Columbia, Jim Pattison Pavilion, 855 W 12th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Andrew W Shih
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Vancouver General Hospital, University of British Columbia, Jim Pattison Pavilion, 899 W 12th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Naisan Garraway
- Division of General Surgery, Trauma and Acute Care Surgery, Vancouver General Hospital, University of British Columbia, Jim Pattison Pavilion, 855 W 12th Ave, Vancouver, BC, V5Z 1M9, Canada
- Canadian Armed Forces, 1 Canadian Field Hospital, 147 Flanders Row, Garrison Petawawa, ON, K8H 2X3, Canada
| | - Philip Dawe
- Division of General Surgery, Trauma and Acute Care Surgery, Vancouver General Hospital, University of British Columbia, Jim Pattison Pavilion, 855 W 12th Ave, Vancouver, BC, V5Z 1M9, Canada
- Canadian Armed Forces, 1 Canadian Field Hospital, 147 Flanders Row, Garrison Petawawa, ON, K8H 2X3, Canada
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Maegele M. [Viscoelasticity-based point of care coagulation diagnostics in the context of resuscitation room management of severely injured and bleeding trauma patients : Diagnostics and treatment of trauma-induced coagulopathy]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:542-551. [PMID: 36976344 DOI: 10.1007/s00113-023-01300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 03/29/2023]
Abstract
Uncontrolled bleeding with associated trauma-induced coagulopathy (TIC) remains the leading cause of preventable death after severe trauma. Meanwhile, TIC is recognized as a separate clinical entity with substantial impact on downstream morbidity and mortality. In clinical practice severely injured and bleeding patients are often still being treated according to established damage control surgery (DCS) procedures with surgical bleeding control and empirical transfusion of classical blood products in predefined ratios in the sense of damage control resuscitation (DCR); however, algorithms are also available, which have been constructed from established viscoelasticity-based point of care (POC) diagnostic procedures and target value-oriented treatments. The latter enables a timely qualitative assessment of coagulation function from whole blood at bedside and provides rapid and clinically useful information on the presence, development and dynamics of the coagulation disorder. The early implementation of viscoelasticity-based POC procedures in the context of resuscitation room management of severely injured and bleeding patients was uniformly associated with reductions in potentially harmful blood products, especially overtransfusions, and an overall improvement in outcome including survival. The present article reviews the clinical questions around the use of viscoelasticity-based procedures as well as recommendations for the early and acute management of bleeding trauma patients taking the current literature into account.
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Affiliation(s)
- Marc Maegele
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln-Merheim, Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Köln, Deutschland.
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Köln, Deutschland.
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12
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Vollmer NJ, Leshko NA, Wilson CS, Gilbert BW. A Review of Thromboelastography for Nurses. Crit Care Nurse 2023; 43:29-37. [PMID: 37257875 DOI: 10.4037/ccn2023371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Thromboelastography is a viscoelastic test with multiple potential advantages over conventional coagulation tests in various disease states. Thromboelastography rapidly provides qualitative and quantitative information related to a patient's coagulation status. OBJECTIVE To describe recent studies of the use of thromboelastography in various clinical states and how thromboelastography is used in coagulation management. METHODS A literature review using the MEDLINE and PubMed databases was conducted. The updated methodology for integrated reviews by Whittemore and Knafl was followed. Coauthors evaluated separate areas that were independently reviewed by other coauthors to ensure appropriateness for inclusion. RESULTS The use of thromboelastography for various clinical conditions with challenging hemostatic profiles has increased. This integrative review covers the use of thromboelastography in patients with trauma, medication-induced coagulopathy, acute and chronic liver failure, and cardiothoracic surgery. Potential future directions are also discussed. DISCUSSION Thromboelastography has numerous potential benefits over conventional coagulation tests for assessing coagulation status in patients in various clinical states. Nurses can support clinical decisions to use the most appropriate test for their patients. CONCLUSIONS Each team member should be involved in assessing the usefulness of thromboelastography. Critical care nurses and the multidisciplinary team must identify patients in whom its use is warranted, interpret the results, and provide appropriate interventions in response to the results and clinical status of the patient.
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Affiliation(s)
- Nicholas J Vollmer
- Nicholas J. Vollmer is an emergency medicine and intensive care unit clinical pharmacy specialist at Mayo Clinic, Rochester, Minnesota
| | - Nicole A Leshko
- Nicole A. Leshko is a critical care pharmacist at Northwestern Memorial Hospital, Chicago, Illinois
| | - Charles S Wilson
- Charles S. Wilson Jr is a postgraduate year 2 critical care pharmacy resident at Wesley Medical Center, Wichita, Kansas
| | - Brian W Gilbert
- Brian W. Gilbert is an emergency medicine clinical pharmacy specialist and Residency Program Director for the Postgraduate Year 2 Critical Care Pharmacy program at Wesley Medical Center
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Bui-Thi HD, Le Minh K. Coagulation profiles in patients with sepsis/septic shock identify mixed hypo-hypercoagulation patterns based on rotational thromboelastometry: A prospective observational study. Thromb Res 2023; 227:51-59. [PMID: 37235948 DOI: 10.1016/j.thromres.2023.05.010] [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: 02/03/2023] [Revised: 04/21/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Sepsis-induced hemostatic disturbances are common and are associated with poor outcomes. Additionally, conventional coagulation tests (CCTs) overdiagnose hypocoagulation and cannot detect hypercoagulation and hyperfibrinolysis. The aim of this study was to describe the coagulation profiles of patients with sepsis/septic shock using rotational thromboelastometry (ROTEM) and to compare coagulation states between sepsis and septic shock groups and between surviving and non-surviving groups. MATERIALS AND METHODS This prospective, observational, single-center study was conducted in the intensive care unit (ICU) of the University Medical Center Ho Chi Minh City, from 6/2020-12/2021. Patients aged ≥18 years with sepsis or septic shock according to the Sepsis-3 criteria were included. ROTEM and CCTs were concurrently performed within the first 24 h of ICU admission. RESULTS In total, 161 patients were enrolled. Based on ROTEM, 72.7 % of patients with sepsis/septic shock had coagulation disorders, including 25.5 % hypercoagulation, 54.7 % hypocoagulation, 13.6 % mixed hypo-hypercoagulation patterns, and 18.6 % hyperfibrinolysis. A common mixed disorder subtype was characterized by prolonged initial clotting time (CT) with subsequently increased clot firmness. Fibrinogen levels and maximum clot formation (MCF)-fibtem were strongly correlated (rho = 0.73, p < 0.05). Hypocoagulation was observed more in the septic shock group than in the sepsis group. Compared to survivors, non-survivors had more prolonged CT-extem. CONCLUSIONS ROTEM could identify hypocoagulability, hypercoagulability, mixed hypo-hypercoagulability patterns, and hyperfibrinolysis in patients with sepsis/septic shock. Elevated MCF-fibtem and elevated fibrinogen levels were notably common and strongly correlated. The septic shock group had more hypocoagulation than the sepsis group. Lastly, non-survivors had more prolonged CT-extem than survivors.
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Affiliation(s)
- Hanh-Duyen Bui-Thi
- Department of Intensive Care, University Medical Center Ho Chi Minh City, The University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang Street, Ward 11, District 5, Ho Chi Minh City, Viet Nam.
| | - Khoi Le Minh
- Department of Science and Training, University Medical Center Ho Chi Minh City, The University of Medicine and Pharmacy at Ho Chi Minh City, Viet Nam.
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Lier H, Gooßen K, Trentzsch H. [The chapters "Stop the bleed-prehospital" and "Coagulation management and volume therapy (emergency departement)" in the new S3 guideline "Polytrauma/severe injury treatment"]. Notf Rett Med 2023; 26:259-268. [PMID: 37261335 PMCID: PMC10117256 DOI: 10.1007/s10049-023-01147-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 06/02/2023]
Abstract
The S3 guideline on the treatment of patients with severe/multiple injuries by the German Association of the Scientific Medical Societies was updated between 2020 and 2022. This article describes the essence of the new chapter "Stop the bleed-prehospital" and the revised chapter "Coagulation management and volume therapy".
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Affiliation(s)
- H. Lier
- Medizinische Fakultät und Uniklinik Köln, Klinik für Anästhesiologie und Operative Intensivmedizin, Universität zu Köln, Kerpener Straße 62, 50937 Köln, Deutschland
- Sektion „Klinische Hämotherapie und Hämostasemanagement“ der Deutschen Gesellschaft für Intensiv- und Notfallmedizin (DIVI), Schumannstr. 2, 10117, Berlin, Deutschland
| | - K. Gooßen
- Institut für Forschung in der Operativen Medizin (IFOM), Universität Witten/Herdecke, Ostmerheimer Straße 200, 51109 Köln, Deutschland
| | - H. Trentzsch
- Institut für Notfallmedizin und Medizinmanagement (INM), Klinikum der Universität München, LMU München, Schillerstr. 53, 80336 München, Deutschland
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15
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David JS, James A, Orion M, Selves A, Bonnet M, Glasman P, Vacheron CH, Raux M. Thromboelastometry-guided haemostatic resuscitation in severely injured patients: a propensity score-matched study. Crit Care 2023; 27:141. [PMID: 37055832 PMCID: PMC10103518 DOI: 10.1186/s13054-023-04421-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/30/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND To accelerate the diagnosis and treatment of trauma-induced coagulopathy (TIC), viscoelastic haemostatic assays (VHA) are increasingly used worldwide, although their value is still debated, with a recent randomised trial showing no improvement in outcome. The objective of this retrospective study was to compare 2 cohorts of injured patients in which TIC was managed with either a VHA-based algorithm or a conventional coagulation test (CCT)-based algorithm. METHODS Data were retrieved from 2 registries and patients were included in the study if they received at least 1 unit of red blood cell in the first 24 h after admission. A propensity score, including sex, age, blunt vs. penetrating, systolic blood pressure, GCS, ISS and head AIS, admission lactate and PTratio, tranexamic acid administration, was then constructed. Primary outcome was the proportion of subjects who were alive and free of massive transfusion (MT) at 24 h after injury. We also compared the cost for blood products and coagulation factors. RESULTS From 2012 to 2019, 7250 patients were admitted in the 2 trauma centres, and among these 624 were included in the study (CCT group: 380; VHA group: 244). After propensity score matching, 215 patients remained in each study group without any significant difference in demographics, vital signs, injury severity, or laboratory analysis. At 24 h, more patients were alive and free of MT in the VHA group (162 patients, 75%) as compared to the CCT group (112 patients, 52%; p < 0.01) and fewer patients received MT (32 patients, 15% vs. 91 patients, 42%, p < 0.01). However, no significant difference was observed for mortality at 24 h (odds ratio 0.94, 95% CI 0.59-1.51) or survival at day 28 (odds ratio 0.87, 95% CI 0.58-1.29). Overall cost of blood products and coagulation factors was dramatically reduced in the VHA group as compared to the CCT group (median [interquartile range]: 2357 euros [1108-5020] vs. 4092 euros [2510-5916], p < 0.001). CONCLUSIONS A VHA-based strategy was associated with an increase of the number of patients alive and free of MT at 24 h together with an important reduction of blood product use and associated costs. However, that did not translate into an improvement in mortality.
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Affiliation(s)
- Jean-Stéphane David
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France.
- Research on Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France.
| | - Arthur James
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Maxime Orion
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France
| | - Agathe Selves
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Mélody Bonnet
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France
| | - Pauline Glasman
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Charles-Hervé Vacheron
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France
- Biometrics and Evolutionary Biology Laboratory, Biostatistics-Health Team, HCL, Villeurbanne, France
- Division of Public Health, Department of Biostatistics and Bioinformatics, Lyon, France
| | - Mathieu Raux
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale Et Clinique; AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Département d'Anesthésie Réanimation, Sorbonne Université, Paris, France
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16
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 98.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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Selby R. “TEG” talks: technology worth spreading? Res Pract Thromb Haemost 2023; 7:100022. [PMID: 36970744 PMCID: PMC10031362 DOI: 10.1016/j.rpth.2022.100022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/08/2022] [Indexed: 03/02/2023] Open
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18
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Volod O, Bunch CM, Miller J, Moore EE, Moore HB, Kwaan HC, Patel SS, Wiarda G, Aboukhaled M, Thomas SG, Fulkerson D, Erdman L, Tincher A, Walsh MM. Reply to Bareille et al. Are Viscoelastometric Assays of Old Generation Ready for Disposal? Comment on "Volod et al. Viscoelastic Hemostatic Assays: A Primer on Legacy and New Generation Devices. J. Clin. Med. 2022, 11, 860". J Clin Med 2023; 12:jcm12020478. [PMID: 36675408 PMCID: PMC9862366 DOI: 10.3390/jcm12020478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/16/2022] [Accepted: 12/27/2022] [Indexed: 01/11/2023] Open
Abstract
We are pleased to see that Bareille et al. have written a Commentary: "Are viscoelastometric assays of old generation ready for disposal?" [...].
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Affiliation(s)
- Oksana Volod
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
- Correspondence:
| | - Connor M. Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48402, USA
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI 48402, USA
| | - Ernest E. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado Health Sciences Center, Denver, CO 80204, USA
| | - Hunter B. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado Health Sciences Center, Denver, CO 80204, USA
| | - Hau C. Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Shivani S. Patel
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Grant Wiarda
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Michael Aboukhaled
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Scott G. Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, Beacon Health System, South Bend, IN 46601, USA
| | - Daniel Fulkerson
- Department of Trauma Surgery, Memorial Leighton Trauma Center, Beacon Health System, South Bend, IN 46601, USA
| | - Lee Erdman
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Anna Tincher
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Mark M. Walsh
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
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Majumdar M, Hall RP, Feldman Z, Goudot G, Sumetsky N, Jessula S, Kirshkaln A, Bellomo T, Chang D, Cardenas J, Patell R, Eagleton M, Dua A. Predicting Arterial Thrombotic Events Following Peripheral Revascularization Using Objective Viscoelastic Data. J Am Heart Assoc 2023; 12:e027790. [PMID: 36565191 PMCID: PMC9973575 DOI: 10.1161/jaha.122.027790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Peripheral artery disease is endemic in our globally aging population, with >200 million affected worldwide. Graft/stent thrombosis after revascularization is common and frequently results in amputation, major adverse cardiovascular events, and cardiovascular mortality. Optimizing medications to decrease thrombosis is of paramount importance; however, limited guidance exists on how to use and monitor antithrombotic therapy in this heterogeneous population. Thromboelastography with platelet mapping (TEG-PM) provides comprehensive coagulation metrics and may be integral to the next stage of patient-centered thrombophrophylaxis. This prospective study aimed to determine if TEG-PM could predict subacute graft/stent thrombosis following lower extremity revascularization, and if objective cut point values could be established to identify those high-risk patients. Methods and Results We conducted a single-center prospective observational study of patients undergoing lower extremity revascularization. Patients were followed up for the composite end point postoperative graft/stent thrombosis at 1 year. TEG-PM analysis of the time point before thrombosis in the event group was compared with the last postoperative visit in the nonevent group. Cox proportional hazards analysis examined the association of TEG-PM metrics to thrombosis. Cut point analysis explored the predictive capacity of TEG-PM metrics for those at high risk. A total of 162 patients were analyzed, of whom 30 (18.5%) experienced graft/stent thrombosis. Patients with thrombosis had significantly greater platelet aggregation (79.7±15.7 versus 58.5±26.4) and lower platelet inhibition (20.7±15.6% versus 41.1±26.6%) (all P<0.01). Cox proportional hazards analysis revealed that for every 1% increase in platelet aggregation, the hazard of experiencing an event during the study period increased by 5% (hazard ratio, 1.05 [95% CI, 1.02-1.07]; P<0.01). An optimal cut point of >70.8% platelet aggregation and/or <29.2% platelet inhibition identifies those at high risk of thrombosis with 87% sensitivity and 70% to 71% specificity. Conclusions Among patients undergoing lower extremity revascularization, increased platelet reactivity was predictive of subacute postoperative graft/stent thrombosis. On the basis of the cut points of >70.8% platelet aggregation and <29.2% platelet inhibition, consideration of an alternative or augmented antithrombotic regimen for high-risk patients may decrease the risk of postoperative thrombotic events.
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Affiliation(s)
- Monica Majumdar
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Ryan P. Hall
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Zachary Feldman
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Guillaume Goudot
- Cardiovascular Research Center, Division of CardiologyMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Natalie Sumetsky
- Department of Epidemiology and StatisticsUniversity of PittsburgPA
| | - Samuel Jessula
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Amanda Kirshkaln
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Tiffany Bellomo
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - David Chang
- Healthcare Research and Policy Development, Codman Center, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Jessica Cardenas
- Center for Translational Injury ResearchUniversity of Texas–HoustonHoustonTX
| | - Rushad Patell
- Division of Hematology/OncologyBeth Israel Deaconess Medical Center/Harvard Medical SchoolBostonMA
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
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20
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Khanna P, Sinha C, Singh AK, Kumar A, Sarkar S. The role of point of care thromboelastography (TEG) and thromboelastometry (ROTEM) in management of Primary postpartum haemorrhage: A meta-analysis and systematic review. Saudi J Anaesth 2023; 17:23-32. [PMID: 37032697 PMCID: PMC10077780 DOI: 10.4103/sja.sja_529_22] [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: 07/18/2022] [Revised: 09/07/2022] [Accepted: 09/11/2022] [Indexed: 12/24/2022] Open
Abstract
Background The utility of instantaneous evaluation of coagulation during primary postpartum haemorrhage (PPH) is paramount in the context of empirical blood product transfusion-related risk of dilutional and consumptive coagulopathy and circulatory overload. Methods A profound screening of electronic databases till August 15, 2022 was carried out after being enlisted in PROSPERO (CRD42021275514). Randomized control studies, comparative cohort studies, and cross-sectional studies comparing point-of-care viscoelastic test guided blood product transfusion with empirical transfusion in patients with PPH were included. Results We retrieved five studies, with a total of 1914 parturient with PPH. Patients receiving transfusion based upon point of care viscoelastic tests had lesser risk of having emergency hysterectomy (Odds ratio (OR) = 0.55, 95% CI 0.32-0.95, I2 = 7%), transfusion-associated circulatory overload (TACO) (OR = 0.03, 95% CI 0.00-0.50), reduced transfusion of fresh frozen plasma (OR = 0.07, 95% CI 0.04-0.14, I2 = 89%), platelets (OR = 0.51, 95% CI 0.28-0.91, I2 = 89%), packed red blood cell transfusion (OR = 0.70, 95% CI 0.55-0.88, I2 = 89%), and had better cost-effective treatment [Mean difference (MD) = -357.5, 95% CI - 567.75 to -147.25, I2 = 93%] than patient received empirical transfusion. However, there was no significant difference in the requirement of ICU admissions (OR = 0.77, 95% CI = 0.46-1.29, I2 = 82%). No mortality was detected across the studies. Conclusions Point of care viscoelastic assessment guided transfusion in PPH confederates with reduced morbidity. Nevertheless, more studies on the triggering values for transfusion, long-term survival, and cost-benefit in patients with PPH are warranted to establish its utility.
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Affiliation(s)
- Puneet Khanna
- Department of Anaesthesia, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Chandni Sinha
- Department of Anesthesia, AIIMS, Patna, Bihar, India
| | - Akhil K. Singh
- Department of Anaesthesia, Pain Medicine and Critical Care, AIIMS, New Delhi, India
| | - Ajeet Kumar
- Department of Anesthesia, AIIMS, Patna, Bihar, India
| | - Soumya Sarkar
- Department of Anesthesia, and Critical Care, AIIMS, Bhubaneswar, Odisha, India
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21
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Pollock GA, Lo J, Chou H, Kissen MS, Kim M, Zhang V, Betz A, Perlman R. Advanced diagnostic and therapeutic techniques for anaesthetists in thoracic trauma: an evidence-based review. Br J Anaesth 2023; 130:e80-e91. [PMID: 36096943 DOI: 10.1016/j.bja.2022.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/27/2022] [Accepted: 07/02/2022] [Indexed: 01/06/2023] Open
Abstract
Anaesthetists play an important role in the evaluation and treatment of patients with signs of thoracic trauma. Anaesthesia involvement can provide valuable input using both advanced diagnostic and therapeutic interventions. Commonly performed interventions may be complicated in this setting including airway management, damage control resuscitation, and acute pain management. Anaesthetists must consider additional factors including airway injuries, vascular injuries, and coagulopathy when treating this population. This evidence-based review discusses traumatic thoracic injuries with a focus on new interventions and modern anaesthesia techniques. This review further serves to support the early involvement of anaesthetists in the emergency department and other areas where they can provide value to the trauma care pathway.
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Affiliation(s)
- Gabriel A Pollock
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Jessie Lo
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Henry Chou
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael S Kissen
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Regional Anaesthesia & Acute Pain Service Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michelle Kim
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vida Zhang
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Thoracic Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Trauma Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexander Betz
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ryan Perlman
- Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Trauma Anaesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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22
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Bunch CM, Chang E, Moore EE, Moore HB, Kwaan HC, Miller JB, Al-Fadhl MD, Thomas AV, Zackariya N, Patel SS, Zackariya S, Haidar S, Patel B, McCurdy MT, Thomas SG, Zimmer D, Fulkerson D, Kim PY, Walsh MR, Hake D, Kedar A, Aboukhaled M, Walsh MM. SHock-INduced Endotheliopathy (SHINE): A mechanistic justification for viscoelastography-guided resuscitation of traumatic and non-traumatic shock. Front Physiol 2023; 14:1094845. [PMID: 36923287 PMCID: PMC10009294 DOI: 10.3389/fphys.2023.1094845] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/07/2023] [Indexed: 03/03/2023] Open
Abstract
Irrespective of the reason for hypoperfusion, hypocoagulable and/or hyperfibrinolytic hemostatic aberrancies afflict up to one-quarter of critically ill patients in shock. Intensivists and traumatologists have embraced the concept of SHock-INduced Endotheliopathy (SHINE) as a foundational derangement in progressive shock wherein sympatho-adrenal activation may cause systemic endothelial injury. The pro-thrombotic endothelium lends to micro-thrombosis, enacting a cycle of worsening perfusion and increasing catecholamines, endothelial injury, de-endothelialization, and multiple organ failure. The hypocoagulable/hyperfibrinolytic hemostatic phenotype is thought to be driven by endothelial release of anti-thrombogenic mediators to the bloodstream and perivascular sympathetic nerve release of tissue plasminogen activator directly into the microvasculature. In the shock state, this hemostatic phenotype may be a counterbalancing, yet maladaptive, attempt to restore blood flow against a systemically pro-thrombotic endothelium and increased blood viscosity. We therefore review endothelial physiology with emphasis on glycocalyx function, unique biomarkers, and coagulofibrinolytic mediators, setting the stage for understanding the pathophysiology and hemostatic phenotypes of SHINE in various etiologies of shock. We propose that the hyperfibrinolytic phenotype is exemplified in progressive shock whether related to trauma-induced coagulopathy, sepsis-induced coagulopathy, or post-cardiac arrest syndrome-associated coagulopathy. Regardless of the initial insult, SHINE appears to be a catecholamine-driven entity which early in the disease course may manifest as hyper- or hypocoagulopathic and hyper- or hypofibrinolytic hemostatic imbalance. Moreover, these hemostatic derangements may rapidly evolve along the thrombohemorrhagic spectrum depending on the etiology, timing, and methods of resuscitation. Given the intricate hemochemical makeup and changes during these shock states, macroscopic whole blood tests of coagulative kinetics and clot strength serve as clinically useful and simple means for hemostasis phenotyping. We suggest that viscoelastic hemostatic assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are currently the most applicable clinical tools for assaying global hemostatic function-including fibrinolysis-to enable dynamic resuscitation with blood products and hemostatic adjuncts for those patients with thrombotic and/or hemorrhagic complications in shock states.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Eric Chang
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States
| | - Hunter B Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, United States.,Department of Transplant Surgery, Denver Health and University of Colorado Health Sciences Center, Denver, CO, United States
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Mahmoud D Al-Fadhl
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Anthony V Thomas
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Nuha Zackariya
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States
| | - Shivani S Patel
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Sufyan Zackariya
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Saadeddine Haidar
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Bhavesh Patel
- Division of Critical Care, Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Scott G Thomas
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Donald Zimmer
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Daniel Fulkerson
- Department of Trauma Surgery, Memorial Leighton Trauma Center, South Bend, IN, United States
| | - Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | - Daniel Hake
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Archana Kedar
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Michael Aboukhaled
- Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Mark M Walsh
- Department of Medical Education, Indiana University School of Medicine, Notre Dame Campus, South Bend, IN, United States.,Departments of Emergency Medicine and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
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23
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Avau B, O D, Veys K, Georgsen J, Nahirniak S, Shehata N, Stanworth SJ, Van Remoortel H, De Buck E, Compernolle V, Vandekerckhove P. Systematic reviews on platelet transfusions: Is there unnecessary duplication of effort? A scoping review. Vox Sang 2023; 118:16-23. [PMID: 36454598 PMCID: PMC10107266 DOI: 10.1111/vox.13387] [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: 05/03/2022] [Revised: 11/03/2022] [Accepted: 11/18/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Platelet transfusions are used across multiple patient populations to prevent and correct bleeding. This scoping review aimed to map the currently available systematic reviews (SRs) and evidence-based guidelines in the field of platelet transfusion. MATERIALS AND METHODS A systematic literature search was conducted in seven databases for SRs on effectiveness (including dose and timing, transfusion trigger and ratio to other blood products), production modalities and decision support related to platelet transfusion. The following data were charted: methodological features of the SR, population, concept and context features, outcomes reported, study design and number of studies included. Results were synthesized in interactive evidence maps. RESULTS We identified 110 SRs. The majority focused on clinical effectiveness, including prophylactic or therapeutic transfusions compared to no platelet transfusion (34 SRs), prophylactic compared to therapeutic-only transfusion (8 SRs), dose, timing (11 SRs) and threshold for platelet transfusion (15 SRs) and the ratio of platelet transfusion to other blood products in massive transfusion (14 SRs). Furthermore, we included 34 SRs on decision support, of which 26 evaluated viscoelastic testing. Finally, we identified 22 SRs on platelet production modalities, including derivation (4 SRs), pathogen inactivation (6 SRs), leucodepletion (4 SRs) and ABO/human leucocyte antigen matching (5 SRs). The SRs were mapped according to concept and clinical context. CONCLUSION An interactive evidence map of SRs and evidence-based guidelines in the field of platelet transfusion has been developed and identified multiple reviews. This work serves as a tool for researchers looking for evidence gaps, thereby both supporting research and avoiding unnecessary duplication.
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Affiliation(s)
- Bert Avau
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
| | - Dorien O
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
| | - Koen Veys
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium
| | - Jørgen Georgsen
- South Danish Transfusion Service & Tissue Center, Department of Clinical Immunology, Odense University Hospital, Odense, Denmark
| | - Susan Nahirniak
- Faculty of Medicine, University of Alberta, Edmonton, Canada.,Transfusion and Transplantation Medicine, Alberta Precision Laboratories, Calgary, Alberta, Canada
| | - Nadine Shehata
- Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium.,Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Emmy De Buck
- Centre for Evidence-Based Practice, Belgian Red Cross, Mechelen, Belgium.,Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
| | - Veerle Compernolle
- Blood Services, Belgian Red Cross, Mechelen, Belgium.,Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Philippe Vandekerckhove
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.,Belgian Red Cross, Mechelen, Belgium.,Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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24
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Hartmann J, Hermelin D, Levy JH. Viscoelastic testing: an illustrated review of technology and clinical applications. Res Pract Thromb Haemost 2022; 7:100031. [PMID: 36760779 PMCID: PMC9903681 DOI: 10.1016/j.rpth.2022.100031] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/07/2022] [Accepted: 11/12/2022] [Indexed: 01/26/2023] Open
Abstract
Viscoelastic testing (VET), including thromboelastography and thromboelastometry, provides a rapid and comprehensive picture of whole blood coagulation dynamics and hemostasis that can be reviewed and evaluated at the point-of-care. This technology is over 50 years old; however, over the past few years, there has been a significant increase in research examining the use of VET. Best practice guidelines for the use of VET exist in both the United States and Europe, particularly for elective cardiac surgery, although recommendations for implementation are somewhat limited in some clinical areas by the lack of studies constituting high-grade evidence. Other challenges to implementation surround validation of the technology in some care settings as well as lack of training. Nevertheless, there is a wide range of potential clinical applications, such as treating coagulopathies in liver disease and transplant surgery, critical care, as well as within obstetrical hemorrhage. In this illustrated review, we provide an overview of viscoelastic testing technology (also called viscoelastic hemostatic assays) and describe how the assays can be used to provide a broad overview of hemostasis from clot formation to clot lysis, while highlighting the contribution of coagulation factors and platelets. We then summarize the major clinical applications for viscoelastic testing, including more recent applications, such as in COVID-19. Each section describes the clinical context, and key publications, followed by a representative algorithm and key guidelines.
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Affiliation(s)
- Jan Hartmann
- Haemonetics Corporation, Boston, Massachusetts, USA
- Correspondence Jan Hartmann, Haemonetics Corporation, Boston, MA 02110, USA. @JanHartmannMD
| | - Daniela Hermelin
- Department of Pathology Saint Louis University School of Medicine, Saint Louis, Missouri, USA
- Medical Affairs, ImpactLife, Davenport, Iowa, USA
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25
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Muacevic A, Adler JR, Clayton LM, Hughes PG, Paley RJ, Shih RD, Alter SM. The Role of Thromboelastography in Identifying Coagulopathy Among Geriatric Traumatic Brain Injury Patients. Cureus 2022; 14:e32818. [PMID: 36694515 PMCID: PMC9863733 DOI: 10.7759/cureus.32818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 12/24/2022] Open
Abstract
Background The geriatric population has the highest incidence of head injury, and those who are anticoagulated have an increased risk of traumatic intracranial hemorrhage (ICH). The availability of viscoelastic coagulation studies has coincided with the development of many anticoagulation reversal agents. In this study, our objective was to assess whether the thromboelastography (TEG) assay affected clinical decision-making regarding reversal agent administration among geriatric patients with ICH caused by blunt head trauma. Methodology We prospectively screened adults aged 65 and older with head trauma presenting to the emergency departments of two level-one trauma centers. International Classification of Diseases, Tenth Revision codes S00-09 were used to identify the diagnosis of head injury. Patients with CT head imaging positive for acute ICH were included. Each patient was assessed for home use of antiplatelet or anticoagulant medications, as well as in-hospital use of any reversal agents. Reversal agent administration and mortality were compared between patients who received TEG and those who did not. Results A total of 680 patients had acute ICH on head CT, and 324 (48%) patients received TEG. More patients screened with TEG were transfused platelets (30.2% vs. 10.7%, p < 0.001). This remained significant for patients taking anticoagulants, antiplatelets, or neither. There were no differences in the administration of other reversal agents (prothrombin complex concentrate or fresh frozen plasma) or mortality whether or not TEG was performed. Conclusions Patients who had TEG performed were more likely to receive platelet reversal agents, regardless of antiplatelet medication usage. Among elderly adults with ICH, TEG is a rapid screening test that may help identify patients with platelet function abnormalities requiring reversal.
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26
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Chen F, Zhang L, Bai X, Wang X, Geng Z. Clinical Application of Thromboelastography in Acute Ischemic Stroke. Clin Appl Thromb Hemost 2022; 28:10760296221131801. [PMID: 36285384 PMCID: PMC9608017 DOI: 10.1177/10760296221131801] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Acute ischemic stroke (AIS), characterized by high morbidity and mortality, has imposed a considerable burden on society. Despite rapid development in the treatment of AIS, there is still a high risk of recurrence. Furthermore, there is a time delay in waiting for the results of conventional coagulation tests in candidate patients for intravenous thrombolysis therapy. Heterogeneous responses to antiplatelet, intravascular thrombolysis, and endovascular therapies also worsen the situation. Thromboelastography (TEG), as a global and portable detection method for hemostasis, facilitates clinicians in disease monitoring, treatment evaluation, and prognosis prediction in AIS. In this narrative review, we provided a comprehensive summary of the clinical application of TEG in ischemic stroke and gave insights to further studies.
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Affiliation(s)
- Feng Chen
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liren Zhang
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaolin Bai
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiuzhe Wang
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China,Zhi Geng, 600 Yishan Road, Xuhui District, Shanghai, 200233 China.
Xiuzhe Wang, 600 Yishan Road, Xuhui District, Shanghai, 200233 China
| | - Zhi Geng
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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27
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Is ROTEM Diagnostic in Trauma Care Associated with Lower Mortality Rates in Bleeding Patients?—A Retrospective Analysis of 7461 Patients Derived from the TraumaRegister DGU®. J Clin Med 2022; 11:jcm11206150. [PMID: 36294471 PMCID: PMC9605144 DOI: 10.3390/jcm11206150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/08/2022] [Accepted: 10/14/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction: Death from uncontrolled trauma haemorrhage and subsequent trauma-induced coagulopathy (TIC) is potentially preventable. Point-of-care devices such as rotational thromboelastometry (ROTEM®) are advocated to detect haemostatic derangements more rapidly than conventional laboratory diagnostics. Regarding reductions in RBC transfusion, the use of ROTEM has been described as being efficient and associated with positive outcomes in several studies. Objective: The effect of ROTEM use was assessed on three different outcome variables: (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality in severely injured patients. Methods and Material: A retrospective analysis of a large data set of severely injured patients collected into the TraumaRegister DGU® between 2009 and 2016 was conducted. The data of 7461 patients corresponded to the inclusion criteria and were subdivided into ROTEM-using and ROTEM-non-using groups. Both groups were analysed regarding (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality. Results: A lower mortality rate in ROTEM-using groups was observed (p = 0.043). Furthermore, more patients received haemostatic medication when ROTEM was used. In ROTEM-using groups, there was a statistically relevant higher application of massive transfusion. Conclusions: In this retrospective study, the use of ROTEM was associated with reduced mortality and an increased application of haemostatics and RBC transfusions. Prospective evidence is needed for further evidence-based recommendations.
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28
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Hartmann J, Dias JD, Pivalizza EG, Garcia-Tsao G. Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials. Semin Thromb Hemost 2022. [DOI: 10.1055/s-0042-1758081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AbstractPatients with cirrhosis often have abnormal hemostasis, with increased risk of hemorrhage and thrombosis. Thromboelastography provides a rapid assessment of the coagulation status and can guide product transfusions in adult patients with cirrhosis. This study aimed to determine whether the use of thromboelastography in adult patients with cirrhosis decreases blood product use and impacts adverse events or mortality compared with standard practice. A registered (PROSPERO CRD42020192458) systematic review and meta-analysis was conducted for randomized controlled trials (RCTs) comparing thromboelastography-guided hemostatic management versus standard practice (control). Co-primary outcomes were the number of transfused platelet units and fresh frozen plasma (FFP) units. Secondary outcomes were mortality, adverse events, utilization of individual blood products, blood loss or excessive bleeding events, hospital/intensive care unit stay, and liver transplant/intervention outcomes. The search identified 260 articles, with five RCTs included in the meta-analysis. Platelet use was five times lower with thromboelastography versus the control, with a relative risk of 0.17 (95% confidence interval [CI]: [0.03–0.90]; p = 0.04), but FFP use did not differ significantly. Thromboelastography was associated with less blood product (p < 0.001), FFP + platelets (p < 0.001), and cryoprecipitate (p < 0.001) use. No differences were reported in bleeding rates or longer term mortality between groups, with the thromboelastography group having lower mortality at 7 days versus the control (relative risk [95% CI] = 0.52 [0.30–0.91]; p = 0.02). Thromboelastography-guided therapy in patients with cirrhosis enhances patient blood management by reducing use of blood products without increasing complications.
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Affiliation(s)
- Jan Hartmann
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, Massachusetts
| | - Joao D. Dias
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, Massachusetts
| | - Evan G. Pivalizza
- Department of Anesthesiology, UT Health McGovern Medical School, Houston, Texas
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut
- VA CT Healthcare System, West Haven, Connecticut
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29
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Study on the Predictive Value of Thromboelastography in Early Neurological Deterioration in Patients with Primary Acute Cerebral Infarction. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:4521003. [PMID: 36199549 PMCID: PMC9527399 DOI: 10.1155/2022/4521003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/09/2022] [Indexed: 01/09/2023]
Abstract
Objective To investigate the predictive value of thromboelastography for the occurrence of early neurological deterioration (END) in patients with primary acute cerebral infarction (ACI). Methods 150 patients who were hospitalized in the department of neurology of our hospital from September 2020 to September 2021 and were clearly diagnosed with primary ACI by head CT and head magnetic resonance imaging (MRI) were selected and divided into END and non-END groups according to the change in National Institute of Health Stroke Scale (NIHSS) score within 72 h of admission. The general baseline data and laboratory indexes of the first examination at admission were compared between the two groups, and the factors that may affect the occurrence of END were determined by univariate analysis and multivariate logistic regression analysis, and the predictive value of thromboelastography on the occurrence of END after ACI was analyzed by applying the receiver operating characteristic (ROC) curve. Results Time to onset, baseline NIHSS score, percentage of diabetes, white blood cell (WBC) levels, C-reactive protein (CRP), and apolipoprotein B (Apo B) levels were higher in the END group than in the non-END group (P < 0.05); coagulation reaction time (RT) (3.97 ± 1.16 vs. 5.49 ± 1.03) and kinetic time (KT) (1.32 ± 0.67 vs. 1.82 ± 0.58) were lower in the END group than in the non-END group (P < 0.05). Inthe END group (P < 0.05) diabetes, baseline NHISS score, CRP level, Apo B level, and RT were independent risk factors for the development of END in patients with ACI (P < 0.05). The AUC of RT to predict the occurrence of END in patients with ACI was 0.855 (95% CI: 0784 to 0925, P = 0.001), with a sensitivity of 81.70% and specificity of 78.00% when the optimal cut-off value was 0.597. Conclusion NIHSS score at admission, CRP, apolipoprotein B, RT shortening, and diabetes mellitus were independent risk factors for the development of END in ACI patients; RT shortening in TEG was predictive of END in ACI patients.
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Meizoso JP, Barrett CD, Moore EE, Moore HB. Advances in the Management of Coagulopathy in Trauma: The Role of Viscoelastic Hemostatic Assays across All Phases of Trauma Care. Semin Thromb Hemost 2022; 48:796-807. [DOI: 10.1055/s-0042-1756305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractUncontrolled bleeding is the leading cause of preventable death following injury. Trauma-induced coagulopathy can manifest as diverse phenotypes ranging from hypocoagulability to hypercoagulability, which can change quickly during the acute phase of trauma care. The major advances in understanding coagulation over the past 25 years have resulted from the cell-based concept, emphasizing the key role of platelets and their interaction with the damaged endothelium. Consequently, conventional plasma-based coagulation testing is not accurate in predicting bleeding and does not provide an assessment of which blood products are indicated. Viscoelastic hemostatic assays (VHA), conducted in whole blood, have emerged as a superior method to guide goal-directed transfusion. The major change in resuscitation has been the shift from unbridled crystalloid loading to judicious balanced blood product administration. Furthermore, the recognition of the rapid changes from hypocoagulability to hypercoagulability has underscored the importance of ongoing surveillance beyond emergent surgery. While the benefits of VHA testing are maximized when used as early as possible, current technology limits use in the pre-hospital setting and the time to results compromises its utility in the emergency department. Thus, most of the reported experience with VHA in trauma is in the operating room and intensive care unit, where there is compelling data to support its value. This overview will address the current and potential role of VHA in the seriously injured patient, throughout the continuum of trauma management.
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Affiliation(s)
- Jonathan P. Meizoso
- DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Christopher D. Barrett
- Center for Precision Cancer Medicine, Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Surgery, Boston University Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Ernest E. Moore
- Department of Surgery, University of Colorado Denver, Aurora, Colorado
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, Colorado
| | - Hunter B. Moore
- Department of Surgery, University of Colorado Denver, Aurora, Colorado
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Utility of viscoelastic hemostatic assay to guide hemostatic resuscitation in trauma patients: a systematic review. World J Emerg Surg 2022; 17:48. [PMID: 36100918 PMCID: PMC9472418 DOI: 10.1186/s13017-022-00454-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022] Open
Abstract
Objective Viscoelastic hemostatic assay (VHA) provides a graphical representation of a clot’s lifespan and reflects the real time of coagulation. It has been used to guide trauma resuscitation; however, evidence of the effectiveness of VHAs is still limited. This systematic review aims to summarize the published evidence to evaluate the VHA-guided strategy in resuscitating trauma patients. Methods The PubMed, Embase, and Web of Science databases were searched from their inception to December 13, 2021. Randomized controlled trials (RCTs) or observational studies comparing VHA-guided transfusion to controls in resuscitating trauma patients were included in this systematic review. Results Of the 7743 records screened, ten studies, including two RCTs and eight observational studies, met the inclusion criteria. There was great heterogeneity concerning study design, enrollment criterion, VHA device, VHA-guided strategy, and control strategy. Thrombelastography (TEG) was used as a guiding tool for transfusion in eight studies, and rotational thromboelastometry (ROTEM), and TEG or ROTEM were used in the other two studies. The overall risk of bias assessment was severe or mild in RCTs and was severe or moderate in observational studies. The main outcomes reported from the included studies were blood transfusion (n = 10), mortality (n = 10), hospital length of stay (LOS) (n = 7), intensive care unit LOS (n = 7), and cost (n = 4). The effect of the VHA-guided strategy was not always superior to the control. Most of the studies did not find significant differences in the transfusion amount of red blood cells (n = 7), plasma (n = 5), platelet (n = 7), cryoprecipitate/fibrinogen (n = 7), and mortality (n = 8) between the VHA-guided group and control group. Notable, two RCTs showed that the VHA-guided strategy was superior or equal to the conventional coagulation test-guided strategy in reducing mortality, respectively. Conclusion Although some studies demonstrated VHA-guided strategy probable benefit in reducing the need for blood transfusion and mortality when resuscitating trauma patients, the evidence is still not robust. The quality of evidence was primarily downgraded by the limited number of included studies and great heterogeneity and severe risk of bias in these. Further studies are strongly recommended. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00454-8.
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Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials. Semin Thromb Hemost 2022. [PMID: 36063848 DOI: 10.1055/s-0042-1757135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Patients with cirrhosis often have abnormal hemostasis, with increased risk of hemorrhage and thrombosis. Thromboelastography provides a rapid assessment of the coagulation status and can guide product transfusions in adult patients with cirrhosis. This study aimed to determine whether the use of thromboelastography in adult patients with cirrhosis decreases blood product use and impacts adverse events or mortality compared with standard practice. A registered (PROSPERO CRD42020192458) systematic review and meta-analysis was conducted for randomized controlled trials (RCTs) comparing thromboelastography-guided hemostatic management versus standard practice (control). Co-primary outcomes were the number of transfused platelet units and fresh frozen plasma (FFP) units. Secondary outcomes were mortality, adverse events, utilization of individual blood products, blood loss or excessive bleeding events, hospital/intensive care unit stay, and liver transplant/intervention outcomes. The search identified 260 articles, with five RCTs included in the meta-analysis. Platelet use was five times lower with thromboelastography versus the control, with a relative risk of 0.17 (95% confidence interval [CI]: [0.03-0.90]; p = 0.04), but FFP use did not differ significantly. Thromboelastography was associated with less blood product (p < 0.001), FFP + platelets (p < 0.001), and cryoprecipitate (p < 0.001) use. No differences were reported in bleeding rates or longer term mortality between groups, with the thromboelastography group having lower mortality at 7 days versus the control (relative risk [95% CI] = 0.52 [0.30-0.91]; p = 0.02). Thromboelastography-guided therapy in patients with cirrhosis enhances patient blood management by reducing use of blood products without increasing complications.
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Hartmann J, Dias JD, Pivalizza EG, Garcia-Tsao G. Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials. Semin Thromb Hemost 2022; 49:162-172. [PMID: 36055266 PMCID: PMC9897960 DOI: 10.1055/s-0042-1753530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with cirrhosis often have abnormal hemostasis, with increased risk of hemorrhage and thrombosis. Thromboelastography provides a rapid assessment of the coagulation status and can guide product transfusions in adult patients with cirrhosis. This study aimed to determine whether the use of thromboelastography in adult patients with cirrhosis decreases blood product use and impacts adverse events or mortality compared with standard practice. A registered (PROSPERO CRD42020192458) systematic review and meta-analysis was conducted for randomized controlled trials (RCTs) comparing thromboelastography-guided hemostatic management versus standard practice (control). Co-primary outcomes were the number of transfused platelet units and fresh frozen plasma (FFP) units. Secondary outcomes were mortality, adverse events, utilization of individual blood products, blood loss or excessive bleeding events, hospital/intensive care unit stay, and liver transplant/intervention outcomes. The search identified 260 articles, with five RCTs included in the meta-analysis. Platelet use was five times lower with thromboelastography versus the control, with a relative risk of 0.17 (95% confidence interval [CI]: [0.03-0.90]; p = 0.04), but FFP use did not differ significantly. Thromboelastography was associated with less blood product (p < 0.001), FFP + platelets (p < 0.001), and cryoprecipitate (p < 0.001) use. No differences were reported in bleeding rates or longer term mortality between groups, with the thromboelastography group having lower mortality at 7 days versus the control (relative risk [95% CI] = 0.52 [0.30-0.91]; p = 0.02). Thromboelastography-guided therapy in patients with cirrhosis enhances patient blood management by reducing use of blood products without increasing complications.
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Affiliation(s)
- Jan Hartmann
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, Massachusetts,Address for correspondence Jan Hartmann, MD, Chief Medical Officer Haemonetics Corporation125 Summer Street, Boston, MA 02110
| | - Joao D. Dias
- Department of Medical Affairs, Clinical Development and Medical Safety, Haemonetics Corporation, Boston, Massachusetts
| | - Evan G. Pivalizza
- Department of Anesthesiology, UT Health McGovern Medical School, Houston, Texas
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut,VA CT Healthcare System, West Haven, Connecticut
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Qiao Y, Lu X. Thromboelastography Parameters in Urosepsis: A Retrospective Study. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:9142489. [PMID: 36072616 PMCID: PMC9402385 DOI: 10.1155/2022/9142489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/30/2022] [Accepted: 07/05/2022] [Indexed: 12/05/2022]
Abstract
Thromboelastography (TEG) is usually used to monitor coagulation disorder clinically. It is unclear whether TEG has association with urosepsis and sepsis-induced coagulopathy (SIC). The purpose of this study was to investigate the clinical significance of TEG parameters in urosepsis. 90 patients who were admitted to the Emergency Ward and Emergency Intensive Care Unit (EICU) of Ren Ji Hospital affiliated to Shanghai Jiao Tong University School of Medicine due to urinary infection from February 2014 to February 2022 were retrospectively studied. Urosepsis patients and non-sepsis patients were separately investigated according to the final discharge diagnosis and Sepsis 3.0. At the same time, patients with urosepsis were further divided into groups of SIC and non-SIC based on the definition of SIC. The data of clinical features, laboratory biomarkers, and TEG parameters were collected and analyzed. There were significant differences in white blood cell count, C-reactive protein (CRP), platelet count, procalcitonin (PCT), fibrinogen (FIB), international normalized ratio (INR), prothrombin time (PT), D-dimer, and incidence of urinary tract obstruction between the urosepsis group and non-sepsis group (P < 0.05). In the comparison with non-sepsis group, K value was significantly lower (P = 0.006), while α-angle (P = 0.003) and clot index (CI) (P = 0.048) were significantly higher in urosepsis group. The area under the K value curve excluding urosepsis was 0.667. The areas under CI and α-angle curves for diagnosing urosepsis were 0.682 and 0.621, respectively. The patients in SIC group had significantly higher K value, lower α-angle, and maximum amplitude (MA) than those in non-SIC group (P < 0.05). Coagulopathy is prone to occur in patients with urosepsis. TEG is helpful for assessment of hypercoagulable state in urosepsis and prediction of hypocoagulability in SIC patients implying the dynamic process of DIC.
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Affiliation(s)
- Yun Qiao
- Department of Emergency Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Xiaoye Lu
- Department of Emergency Medicine, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
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Mamczak CN, Speybroeck J, Stillson JE, Dynako J, Piscoya A, Peck EE, Aboukhaled M, Cancel E, McDonald M, Garcia D, Lovejoy J, Lubin S, Stanton R, Kutcher ME. Viscoelastic Hemostatic Assays for Orthopedic Trauma and Elective Procedures. J Clin Med 2022; 11:jcm11144029. [PMID: 35887803 PMCID: PMC9323142 DOI: 10.3390/jcm11144029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
The application of viscoelastic hemostatic assays (VHAs) (e.g., thromboelastography (TEG) and rotational thromboelastometry (ROTEM)) in orthopedics is in its relative infancy when compared with other surgical fields. Fortunately, several recent studies describe the emerging use of VHAs to quickly and reliably analyze the real-time coagulation and fibrinolytic status in both orthopedic trauma and elective orthopedic surgery. Trauma-induced coagulopathy—a spectrum of abnormal coagulation phenotypes including clotting factor depletion, inadequate thrombin generation, platelet dysfunction, and dysregulated fibrinolysis—remains a potentially fatal complication in severely injured and/or hemorrhaging patients whose timely diagnosis and management are aided by the use of VHAs. Furthermore, VHAs are an invaluable compliment to common coagulation tests by facilitating the detection of hypercoagulable states commonly associated with orthopedic injury and postoperative status. The use of VHAs to identify hypercoagulability allows for an accurate venous thromboembolism (VTE) risk assessment and monitoring of VTE prophylaxis. Until now, the data have been insufficient to permit an individualized approach with regard to dosing and duration for VTE thromboprophylaxis. By incorporating VHAs into routine practice, orthopedic surgeons will be better equipped to diagnose and treat the complete spectrum of coagulation abnormalities faced by orthopedic patients. This work serves as an educational primer and up-to-date review of the current literature on the use of VHAs in orthopedic surgery.
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Affiliation(s)
- Christiaan N. Mamczak
- Department of Orthopaedic Trauma, Florida Orthopaedic Institute, St. Petersburg, FL 33701, USA;
| | - Jacob Speybroeck
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA;
| | - John E. Stillson
- Department of Family Medicine, John Peter Smith Hospital, Fort Worth, TX 76104, USA
- Correspondence:
| | - Joseph Dynako
- Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Andres Piscoya
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA;
| | - Ethan E. Peck
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Michael Aboukhaled
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Emily Cancel
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - Michael McDonald
- Department of Graduate Medical Education, Naval Medical Readiness and Training Command, Portsmouth, VA 23708, USA;
| | - Diego Garcia
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (E.E.P.); (M.A.); (E.C.); (D.G.)
| | - John Lovejoy
- Department of Orthopaedic Surgery, University of Florida Health Jacksonville, Jacksonville, FL 32209, USA;
| | - Stephanie Lubin
- Department of Orthopaedic Surgery, Hôpital Sacré Coeur, Milot 1230, Haiti;
| | - Robert Stanton
- Department of Pediatric Orthopaedics, Nemours Children’s Health-Florida, Orlando, FL 32827, USA;
| | - Matthew E. Kutcher
- Departments of Surgery and Emergency Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA;
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The coagulopathy underlying rotational thromboelastometry derangements in trauma patients: a prospective observational multicenter study. Anesthesiology 2022; 137:232-242. [PMID: 35544678 DOI: 10.1097/aln.0000000000004268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Viscoelastic hemostatic assays such as rotational thromboelastometry (ROTEM®) are used to guide treatment of trauma induced coagulopathy. We hypothesized that ROTEM derangements reflect specific coagulation factor deficiencies after trauma. METHODS Secondary analysis of a prospective cohort study in six European trauma centers in patients presenting with full trauma team activation. Patients with dilutional coagulopathy and patients on anticoagulants were excluded. Blood was drawn on arrival for measurement of ROTEM®, coagulation factor levels and markers of fibrinolysis. ROTEM® cut-off values to define hypocoagulability were: EXTEM clotting time (CT) >80s, EXTEM clot amplitude after 5 minutes (CA5) <40mm, EXTEM lysis at 30 minutes (Li30) <85%, FIBTEM clot amplitude after 5 minutes (CA5) <10mm and FIBTEM lysis at 30 minutes (Li30) <85%. Based on these, patients were divided into 7 deranged ROTEM® profiles and compared to the reference group (ROTEM® values within reference range). The primary endpoint was coagulation factors levels and fibrinolysis. RESULTS Of 1828 patients, 40% had ROTEM® derangements 40.0%, most often consisting of a combined decrease in EXTEM and FIBTEM CA5, that was present in 217 (11.9%) patients. While an isolated EXTEM CT>80s had no impact on mortality, all other ROTEM® derangements were associated with increased mortality. Also, coagulation factor levels in this group were similar to patients with a normal ROTEM®. Of coagulation factors, decrease was most apparent for fibrinogen (with a nadir of 0.78 g/L) and for factor V levels (with a nadir of 22.8%). In addition, increased fibrinolysis can be present when LI30 is normal but EXTEM and FIBTEM CA5 is decreased. CONCLUSION Coagulation factor levels and mortality in the group with an isolated clotting time prolongation is similar to patients with a normal ROTEM ®. Other ROTEM ® derangements are associated with mortality and reflect a depletion of fibrinogen and factor V. Increased fibrinolysis can be present when lysis after 30 minutes is normal.
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Aichholz PK, Lee SA, Farr CK, Tsang HC, Vavilala MS, Stansbury LG, Hess JR. Platelet Transfusion and Outcomes After Massive Transfusion Protocol Activation for Major Trauma: A Retrospective Cohort Study. Anesth Analg 2022; 135:385-393. [PMID: 35522847 DOI: 10.1213/ane.0000000000005982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Incorporation of massive transfusion protocols (MTPs) into acute major trauma care has reduced hemorrhagic mortality, but the threshold and timing of platelet transfusion in MTP are controversial. This study aimed to describe early (first 4 hours) platelet transfusion practice in a setting where platelet counts are available within 15 minutes and the effect of early platelet deployment on in-hospital mortality. Our hypothesis in this work was that platelet transfusion in resuscitation of severe trauma can be guided by rapid turnaround platelet counts without excess mortality. METHODS We examined MTP activations for all admissions from October 2016 to September 2018 to a Level 1 regional trauma center with a full trauma team activation. We characterized platelet transfusion practice by demographics, injury severity, and admission vital signs (as shock index: heart rate/systolic blood pressure) and laboratory results. A multivariable model assessed association between early platelet transfusion and mortality at 4 hours, 24 hours, and overall in-hospital, with P <.001. RESULTS Of the 11,474 new trauma patients admitted over the study period, 469 (4.0%) were massively transfused (defined as ≥10 units of red blood cells [RBCs] in 24 hours, ≥5 units of RBC in 6 hour, ≥3 units of RBC in 1 hour, or ≥4 units of total products in 30 minutes). 250 patients (53.0%) received platelets in the first 4 hours, and most early platelet transfusions occurred in the first hour after admission (175, 70.0%). Platelet recipients had higher injury severity scores (mean ± standard deviation [SD], 35 ± 16 vs 28 ± 14), lower admission platelet counts (189 ± 80 × 109/L vs 234 ± 80 × 109/L; P < .001), higher admission shock index (heart rate/systolic blood pressure; 1.15 ± 0.46 vs 0.98 ± 0.36; P < .001), and received more units of red cells in the first 4 hours (8.7 ± 7.7 vs 3.3 ± 1.6 units), 24 hours (9 ± 9 vs 3 ± 2 units), and in-hospital (9 ± 8 vs 3 ± 2 units) than nonrecipients (all P < .001). We saw no difference in 4-hour (8% vs 7.8%; P = .4), 24-hour (16.4% vs 10.5%; P = .06), or in-hospital mortality (30.4% vs 23.7%; P = .1) between platelet recipients and nonrecipients. After adjustment for age, injury severity, head injury, and admission physiology/laboratory results, early platelet transfusion was not associated with 4-hour, 24-hour, or in-hospital mortality. CONCLUSIONS In an advanced trauma care setting where platelet counts are available within 15 minutes, approximately half of massively transfused patients received early platelet transfusion. Early platelet transfusion guided by protocol-based clinical judgment and rapid-turnaround platelet counts was not associated with increased mortality.
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Affiliation(s)
- Pudkrong K Aichholz
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Sarah A Lee
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital-Harvard University, Boston, Massachusetts
| | - Carly K Farr
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Hamilton C Tsang
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Monica S Vavilala
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.,Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Lynn G Stansbury
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.,Harborview Injury Prevention and Research Center, Seattle, Washington
| | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
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Richards JE, Fedeles BT. Coagulation Management in Trauma: Do We Need a Viscoelastic Hemostatic Assay? CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Llompart-Pou JA, Chico-Fernández M. Traumatic critical hemorrhage. Future challenges. Med Intensiva 2022; 46:217-220. [PMID: 35210173 DOI: 10.1016/j.medine.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 06/14/2023]
Affiliation(s)
- J A Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain.
| | - M Chico-Fernández
- Unidad de Cuidados Intensivos de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
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The Non-Activated Thromboelastometry (NATEM) Assay's Application among Adults and Neonatal/Pediatric Population: A Systematic Review. Diagnostics (Basel) 2022; 12:diagnostics12030658. [PMID: 35328210 PMCID: PMC8947108 DOI: 10.3390/diagnostics12030658] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/21/2022] [Accepted: 03/03/2022] [Indexed: 02/06/2023] Open
Abstract
The non-activated thromboelastometry (NATEM) assay is a point-of-care assay that can provide a comprehensive insight into the actual hemostatic mechanism. However, there are very limited data about its use in clinical practice. The aim of this study was to systematically review the literature for any data regarding the use of NATEM in several clinical settings. A systematic review of PubMed and Scopus databases was conducted through 20 January 2022 for studies evaluating the use of the NATEM assay in different clinical settings. The literature search yielded a total of 47 publications, 30 of which met the eligibility criteria for this review. Evaluation of NATEM’s detecting ability for hemostasis disorders is limited in the literature. The results of the included studies indicate that NATEM seems to be a sensitive method for the detection of hyperfibrinolysis and may have an advantage in the diagnosis of hemostatic disorders. It could be more informative than the other ROTEM assays for detecting changes in coagulation parameters in patients who receive anticoagulants. However, the reported outcomes are highly varying among the included studies. NATEM has a high sensitivity to detect hypo- or hypercoagulability and provides a detailed insight into the whole hemostatic process from clot formation to clot breakdown. It could be a useful technique in variable fields of medicine, not only in adults, but also in pediatric and neonatal populations, to guide different hemostatic treatments and predict coagulation disorders or mortality/morbidity; this issue remains to be further investigated.
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Dias JD, Butwick AJ, Hartmann J, Waters JH. Viscoelastic haemostatic point-of-care assays in the management of postpartum haemorrhage: a narrative review. Anaesthesia 2022; 77:700-711. [PMID: 35194779 DOI: 10.1111/anae.15662] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 01/29/2023]
Abstract
Viscoelastic haemostatic assays provide rapid testing at the bed-side that identify all phases of haemostasis, from initial fibrin formation to clot lysis. In obstetric patients, altered haemostasis is common as pregnancy is associated with coagulation changes that may contribute to bleeding events such as postpartum haemorrhage, as well as thrombosis events. In this narrative review, we examine the potential clinical utility of viscoelastic haemostatic assays in postpartum haemorrhage and consider the current recommendations for their use in obstetric patients. We discuss the clinical benefits associated with the use of viscoelastic haemostatic assays due to the provision of (near) real-time readouts with a short turnaround, coupled with the identification of coagulation defects such as hypofibrinogenaemia. The use of viscoelastic haemostatic assay-guided algorithms may be beneficial to diagnose coagulopathy, predict postpartum haemorrhage, reduce transfusion requirements and monitor fibrinolysis in women with obstetric haemorrhage. Further studies are required to assess whether viscoelastic haemostatic assay-guided treatment improves clinical outcomes, and to confirm the utility of prepartum viscoelastic haemostatic assay measurements for identifying patients at risk of postpartum haemorrhage.
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Affiliation(s)
- J D Dias
- Haemonetics Corporation, Boston, MA, USA
| | - A J Butwick
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA
| | - J Hartmann
- Haemonetics Corporation, Boston, MA, USA
| | - J H Waters
- Department of Anesthesiology and Bioengineering, University of Pittsburgh and McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
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Marsee MK, Shariff FS, Wiarda G, Watson PJ, Sualeh AH, Brenner TJ, McCoy ML, Al-Fadhl HD, Jones AJ, Davis PK, Zimmer D, Folsom C. Use of Thromboelastography and Rotational Thromboelastometry in Otolaryngology: A Narrative Review. J Clin Med 2022; 11:jcm11041119. [PMID: 35207392 PMCID: PMC8876674 DOI: 10.3390/jcm11041119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/09/2022] [Accepted: 02/18/2022] [Indexed: 01/27/2023] Open
Abstract
In the field of otolaryngology—head and neck surgery (ENT), coagulopathies present unique diagnostic and therapeutic challenges. In both hyper- and hypocoagulable patients, management of coagulopathies requires intricate attention to the nature of hemostatic competence. Common coagulation tests (CCTs) offer only a snapshot of hemostatic competence and do not provide a clear insight into the patient’s real-time hemostatic condition. Viscoelastic tests (VETs) offer a holistic and concurrent picture of the coagulation process. Although VETs have found prominent utilization in hepatic transplants, obstetrics, and emergent surgical settings, they have not been fully adopted in the realm of otolaryngology. The objective of this manuscript is to provide an overview of the literature evaluating the current utilization and possible future uses of VETs in the field of otolaryngology. The authors performed a comprehensive literature search of the utilization of VETs in otolaryngology and identified applicable studies that included descriptions of viscoelastic testing. Twenty-five studies were identified in this search, spanning topics from head and neck oncology, microvascular free flap reconstruction, obstructive sleep apnea, adenotonsillectomy, facial trauma, and epistaxis. The applicability of VETs has been demonstrated in head and neck oncology and microvascular free flap management, although their pervasiveness in practice is limited. Underutilization of VETs in the field of otolaryngology may be due to a lack of familiarity of the tests amongst practitioners. Instead, most otolaryngologists continue to rely on CCTs, including PT, PTT, INR, CBC, fibrinogen levels, and thrombin time. Learning to perform, interpret, and skillfully employ VETs in clinical and operative practice can greatly improve the management of coagulopathic patients who are at increased risk of bleeding or thrombosis.
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Affiliation(s)
- Mathew K. Marsee
- Department of Graduate Medical Education, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA
- Correspondence:
| | - Faisal S. Shariff
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (F.S.S.); (P.J.W.)
| | - Grant Wiarda
- Department of Biological Sciences, Vanderbilt University, Nashville, TN 37235, USA;
| | - Patrick J. Watson
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (F.S.S.); (P.J.W.)
| | - Ali H. Sualeh
- Department of Biochemistry, Indiana University Bloomington, Bloomington, IN 47405, USA; (A.H.S.); (M.L.M.); (H.D.A.-F.)
| | - Toby J. Brenner
- Department of Biochemistry, Indiana Wesleyan University, Marion, IN 46953, USA;
| | - Max L. McCoy
- Department of Biochemistry, Indiana University Bloomington, Bloomington, IN 47405, USA; (A.H.S.); (M.L.M.); (H.D.A.-F.)
| | - Hamid D. Al-Fadhl
- Department of Biochemistry, Indiana University Bloomington, Bloomington, IN 47405, USA; (A.H.S.); (M.L.M.); (H.D.A.-F.)
| | - Alexander J. Jones
- Department of Otolaryngology, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (A.J.J.); (P.K.D.)
| | - Patrick K. Davis
- Department of Otolaryngology, Indiana University School of Medicine, Indianapolis, IN 46202, USA; (A.J.J.); (P.K.D.)
| | - David Zimmer
- Cleveland Clinic Foundation, Cleveland, OH 44195, USA;
| | - Craig Folsom
- Department of Otolaryngology, Navy Medicine Readiness and Training Command, Portsmouth, VA 23708, USA;
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Viscoelastic Hemostatic Assays: A Primer on Legacy and New Generation Devices. J Clin Med 2022; 11:jcm11030860. [PMID: 35160311 PMCID: PMC8836477 DOI: 10.3390/jcm11030860] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 02/06/2023] Open
Abstract
Viscoelastic hemostatic assay (VHAs) are whole blood point-of-care tests that have become an essential method for assaying hemostatic competence in liver transplantation, cardiac surgery, and most recently, trauma surgery involving hemorrhagic shock. It has taken more than three-quarters of a century of research and clinical application for this technology to become mainstream in these three clinical areas. Within the last decade, the cup and pin legacy devices, such as thromboelastography (TEG® 5000) and rotational thromboelastometry (ROTEM® delta), have been supplanted not only by cartridge systems (TEG® 6S and ROTEM® sigma), but also by more portable point-of-care bedside testing iterations of these legacy devices (e.g., Sonoclot®, Quantra®, and ClotPro®). Here, the legacy and new generation VHAs are compared on the basis of their unique hemostatic parameters that define contributions of coagulation factors, fibrinogen/fibrin, platelets, and clot lysis as related to the lifespan of a clot. In conclusion, we offer a brief discussion on the meteoric adoption of VHAs across the medical and surgical specialties to address COVID-19-associated coagulopathy.
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Is it possible to improve prediction of outcome and blood requirements in the severely injured patients by defining categories of coagulopathy? Eur J Trauma Emerg Surg 2022; 48:2751-2761. [PMID: 35118557 DOI: 10.1007/s00068-022-01882-6] [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: 09/21/2021] [Accepted: 01/17/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE It has been suggested to define the Trauma-induced coagulopathy (TIC) with a PTratio threshold of 1.20. We hypothesized that a more pragmatic classification would grade severity according to the PTratio (or corresponding ROTEM clotting time: EXTEM-CT), and that this would correlate better with the need for blood products (BP) and prognosis. METHODS Retrospective analysis of prospectively collected data of 1076 severely injured patients admitted from 01/2011 to 12/2019 in a university hospital. To determine the number of TIC categories and the best PTratio or EXTEM-CT thresholds for mortality at 24-h, a modified Mazumdar approach was used. Multivariate regression analyses were done to describe the relationship between PTratio and ROTEM parameter subclasses with mortality. RESULTS Three thresholds were, respectively, identified for PTratio (1.20, 1.90 and 3.00) and EXTEM-CT (90 s, 130 s, 200 s). The following categories were defined for PTratio: ≤ 1.20 (No TIC), 1.21-1.90 (Moderate TIC), 1.91-3.00 (severe TIC), > 3.00 (major TIC); and for EXTEM-CT: < 91 s (no TIC), 91-130 s (moderate TIC), 131-200 s (severe TIC) and > 200 s (major TIC). We observed that when the PTratio (or EXTEM-CT) increased, mortality and BP requirements increased. After multiple adjustments, we observed that each subclass of PTratio and EXTEM-CT was independently associated with mortality at 24-h. CONCLUSION In this study, we have described a pragmatic classification of coagulopathy utilizing PTratio and EXTEM-CT where increasing severity was associated with prognosis and the amount of BP administered. This could allow clinicians to better predict the outcome and anticipate the need for blood products.
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Lier H, Fries D. Emergency Blood Transfusion for Trauma and Perioperative Resuscitation: Standard of Care. Transfus Med Hemother 2022; 48:366-376. [PMID: 35082568 DOI: 10.1159/000519696] [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: 07/13/2021] [Accepted: 09/08/2021] [Indexed: 11/19/2022] Open
Abstract
Uncontrolled and massive bleeding with derangement of coagulation is a major challenge in the management of both surgical and seriously injured patients. The underlying mechanism of trauma-induced or -associated coagulopathy is tissue injury in the presence of shock and acidosis provoking endothelial damage, activation of inflammation, and coagulation disbalancing. Furthermore, the combination of ongoing blood loss and consumption of blood components that are essential for effective coagulation worsens uncontrolled hemorrhage. Additionally, therapeutic actions, such as resuscitation with replacement fluids or allogeneic blood products, can further aggravate coagulopathy. Of the coagulation factors essential to the clotting process, fibrinogen is the first to be consumed to critical levels during acute bleeding and current evidence suggests that normalizing fibrinogen levels in bleeding patients improves clot formation and clot strength, thereby controlling hemorrhage. Three different therapeutic approaches are discussed controversially. Whole blood transfusion is used especially in the military scenario and is also becoming more and more popular in the civilian world, although it is accompanied by a strong lack of evidence and severe safety issues. Transfusion of allogeneic blood concentrates in fixed ratios without any targets has been investigated extensively with disappointing results. Individualized and target-controlled coagulation management based on point-of-care diagnostics with respect to the huge heterogeneity of massive bleeding situations is an alternative and advanced approach to managing coagulopathy associated with massive bleeding in the trauma as well as the perioperative setting.
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Affiliation(s)
- Heiko Lier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic for Anesthesiology and Intensive Care Medicine, Cologne, Germany
| | - Dietmar Fries
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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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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David JS, Lambert A, Taverna XJ, Incagnoli P, Geay-Baillat MO, Vassal O, Friggeri A, Inaba K. Which injured patients with moderate fibrinogen deficit need fibrinogen supplementation? Scand J Trauma Resusc Emerg Med 2021; 29:174. [PMID: 34952618 PMCID: PMC8709958 DOI: 10.1186/s13049-021-00988-x] [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: 09/03/2021] [Accepted: 12/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background In severely injured patients, fibrinogen supplementation is recommended when fibrinogenemia is < 1.5 g L−1, but some teams have suggested to use higher thresholds (fibrinogenemia < 2.0 g L−1 or FIBTEM clot amplitude at 5 min (A5) values < 11 mm). The goal of this study was to specify in patients with a moderate fibrinogen deficit (MFD) whether some admission characteristics would be associated with fibrinogen administration at 24 h. Methods Prospective analysis of retrospectively collected data from a trauma registry (01/2011–12/2019). MFD-C was defined by a fibrinogenemia 1.51–1.99 g L−1 or the corresponding FIBTEM-A5 values (MFD-A5) that were determined from linear regression and ROC curve analysis. Administration of fibrinogen were described according to the following admission parameters: shock index (SI) > 1, hemoglobin level < 110 g L−1 (HemoCue®), and base deficit > 5 mEq L−1. Data are expressed as count (%), median [IQR]. Results 1076 patients were included in the study and 266 (27%) had MFD-C, among them, 122/266 (46%) received fibrinogen. Patients with MFD-C who received fibrinogen were more severely injured (ISS: 27 [19–36] vs. 24 [17–29]) and had more impaired vital signs (base deficit: 5.4 [3.6–7.8] vs. 3.8 [2.0–6.0]). Linear regression analysis found a positive correlation between fibrinogen level and FIBTEM-A5 (r: 0.805). For a fibrinogen level < 1.5 g L−1 and < 2.0 g L−1, FIBTEM-A5 thresholds were 6 mm (sensitivity 85%, specificity 83%, AUC: 0.934) and 9 mm (sensitivity 84%, specificity 69%, AUC: 0.874), respectively. MFD-A5 values (185 (27%) patients) were defined as a FIBTEM-A5 between 7 and 9 mm. More than 50% of MFD-C patients presenting a SI > 1, a hemoglobin level < 110 g L−1, or a base deficit > 5.0 mEq L−1 received fibrinogen. The relative risk [95% CI] for fibrinogen administration (SI > 1) were 1.39 [1.06–1.82] for MFD-C, and 2.17 [1.48–3.19] for MFD-A5. Results were not modified after adjustment on the ISS. Conclusions We have shown in this study an association between shock parameters and fibrinogen administration. Further studies are needed to determine how these parameters may be used to guide fibrinogen administration in trauma patients with MFD.
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Affiliation(s)
- Jean-Stephane David
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France. .,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France. .,Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France. .,Service d'Anesthésie Réanimation, Centre Hospitalier Lyon Sud, 69495, Pierre Bénite cedex, France.
| | - Aline Lambert
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Xavier-Jean Taverna
- Service d'anesthésie-réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, 69008, Lyon, France
| | - Pascal Incagnoli
- Service des Urgences - SAMU, Hôpital Universitaire de Dijon, Dijon, France
| | - Marie-Odile Geay-Baillat
- Laboratoire d'Hémostase, Hôpital Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France
| | - Olivia Vassal
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Arnaud Friggeri
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Kenji Inaba
- Division of Trauma and Critical Care, Department of Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
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Abstract
PURPOSE OF REVIEW Patients admitted to ICUs are a heterogeneous group, displaying multiple anaemia risk factors and comorbidities. Clinicians should therefore take all possible measures to identify modifiable risks. Patient Blood Management (PBM) is an approach promoting the timely application of evidence-based interventions designed to maintain patients own blood mass. RECENT FINDINGS Within ICU-patients, anaemia is highly prevalent. Generally, anaemia is associated with impaired outcome and need of blood transfusion. Currently, with ICUs working at full capacity and the global blood reserves exhausted, the SARS-CoV-2 pandemic reinforces the need for PBM implementation. For instance, implementation of a comprehensive coagulation management and measures to avoid iatrogenic blood loss may prevent bleeding-associated complications and adherence to blood transfusion guidelines may reduce adverse events associated with transfusion. SUMMARY Critically ill patients display various morbidities often requiring individualized treatment. PBM offers patient-centred measures to improve outcome any time during hospital stay.
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Bradbury JL, Thomas SG, Sorg NR, Mjaess N, Berquist MR, Brenner TJ, Langford JH, Marsee MK, Moody AN, Bunch CM, Sing SR, Al-Fadhl MD, Salamah Q, Saleh T, Patel NB, Shaikh KA, Smith SM, Langheinrich WS, Fulkerson DH, Sixta S. Viscoelastic Testing and Coagulopathy of Traumatic Brain Injury. J Clin Med 2021; 10:jcm10215039. [PMID: 34768556 PMCID: PMC8584585 DOI: 10.3390/jcm10215039] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/24/2021] [Accepted: 10/27/2021] [Indexed: 12/14/2022] Open
Abstract
A unique coagulopathy often manifests following traumatic brain injury, leading the clinician down a difficult decision path on appropriate prophylaxis and therapy. Conventional coagulation assays—such as prothrombin time, partial thromboplastin time, and international normalized ratio—have historically been utilized to assess hemostasis and guide treatment following traumatic brain injury. However, these plasma-based assays alone often lack the sensitivity to diagnose and adequately treat coagulopathy associated with traumatic brain injury. Here, we review the whole blood coagulation assays termed viscoelastic tests and their use in traumatic brain injury. Modified viscoelastic tests with platelet function assays have helped elucidate the underlying pathophysiology and guide clinical decisions in a goal-directed fashion. Platelet dysfunction appears to underlie most coagulopathies in this patient population, particularly at the adenosine diphosphate and/or arachidonic acid receptors. Future research will focus not only on the utility of viscoelastic tests in diagnosing coagulopathy in traumatic brain injury, but also on better defining the use of these tests as evidence-based and/or precision-based tools to improve patient outcomes.
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Affiliation(s)
- Jamie L. Bradbury
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Scott G. Thomas
- Department of Trauma Surgery, Memorial Hospital, South Bend, IN 46601, USA;
| | - Nikki R. Sorg
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Nicolas Mjaess
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Margaret R. Berquist
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Toby J. Brenner
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Jack H. Langford
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Mathew K. Marsee
- Department of Otolaryngology, Portsmouth Naval Medical Center, Portsmouth, VA 23708, USA;
| | - Ashton N. Moody
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Connor M. Bunch
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
- Correspondence:
| | - Sandeep R. Sing
- Department of Emergency Medicine, Indiana University School of Medicine—South Bend, South Bend, IN 46617, USA; (N.R.S.); (A.N.M.); (S.R.S.)
| | - Mahmoud D. Al-Fadhl
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Qussai Salamah
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Tarek Saleh
- Department of Intensive Care Medicine, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA; (N.M.); (M.R.B.); (T.J.B.); (J.H.L.); (M.D.A.-F.); (Q.S.); (T.S.)
| | - Neal B. Patel
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Kashif A. Shaikh
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Stephen M. Smith
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Walter S. Langheinrich
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Daniel H. Fulkerson
- Department of Neurosurgery, Memorial Hospital, South Bend, IN 46601, USA; (N.B.P.); (K.A.S.); (S.M.S.); (W.S.L.); (D.H.F.)
- Department of Neurosurgery, St. Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Sherry Sixta
- Department of Trauma Surgery, Envision Physician Services, Plano, TX 75093, USA;
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Fecher A, Stimpson A, Ferrigno L, Pohlman TH. The Pathophysiology and Management of Hemorrhagic Shock in the Polytrauma Patient. J Clin Med 2021; 10:jcm10204793. [PMID: 34682916 PMCID: PMC8541346 DOI: 10.3390/jcm10204793] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
The recognition and management of life-threatening hemorrhage in the polytrauma patient poses several challenges to prehospital rescue personnel and hospital providers. First, identification of acute blood loss and the magnitude of lost volume after torso injury may not be readily apparent in the field. Because of the expression of highly effective physiological mechanisms that compensate for a sudden decrease in circulatory volume, a polytrauma patient with a significant blood loss may appear normal during examination by first responders. Consequently, for every polytrauma victim with a significant mechanism of injury we assume substantial blood loss has occurred and life-threatening hemorrhage is progressing until we can prove the contrary. Second, a decision to begin damage control resuscitation (DCR), a costly, highly complex, and potentially dangerous intervention must often be reached with little time and without sufficient clinical information about the intended recipient. Whether to begin DCR in the prehospital phase remains controversial. Furthermore, DCR executed imperfectly has the potential to worsen serious derangements including acidosis, coagulopathy, and profound homeostatic imbalances that DCR is designed to correct. Additionally, transfusion of large amounts of homologous blood during DCR potentially disrupts immune and inflammatory systems, which may induce severe systemic autoinflammatory disease in the aftermath of DCR. Third, controversy remains over the composition of components that are transfused during DCR. For practical reasons, unmatched liquid plasma or freeze-dried plasma is transfused now more commonly than ABO-matched fresh frozen plasma. Low-titer type O whole blood may prove safer than red cell components, although maintaining an inventory of whole blood for possible massive transfusion during DCR creates significant challenges for blood banks. Lastly, as the primary principle of management of life-threatening hemorrhage is surgical or angiographic control of bleeding, DCR must not eclipse these definitive interventions.
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Affiliation(s)
- Alison Fecher
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Anthony Stimpson
- Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA; (A.F.); (A.S.)
| | - Lisa Ferrigno
- Department of Surgery, UCHealth, University of Colorado-Denver, Aurora, CO 80045, USA;
| | - Timothy H. Pohlman
- Surgery Section, Woodlawn Hospital, Rochester, IN 46975, USA
- Correspondence:
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