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Cummings CO, Eisenbarth J, deLaforcade A. Viscoelastic Coagulation Testing in Exotic Animals. Vet Clin North Am Exot Anim Pract 2022; 25:597-612. [PMID: 36122942 DOI: 10.1016/j.cvex.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Whole blood viscoelastic coagulation testing (VCT) allows global assessment of hemostasis and fibrinolysis. Although not widely used in exotic animal practice, VCT has been used in exotic animal research settings. Differences in patient demographics and analytical variables can result in dramatically different results with the same analyzer. To improve the utility of VCT in exotic animal medicine, standardization of protocols is necessary to facilitate the establishment of reference intervals. Despite these challenges, the quantitative/qualitative nature of VCT has already proved its real-world value to some clinicians.
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Affiliation(s)
- Charles O Cummings
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, 35 Kneeland Street Suite 8, Boston, MA 0211, USA.
| | - Jessica Eisenbarth
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, 200 Westboro Road, North Grafton, MA 01536, USA
| | - Armelle deLaforcade
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, 200 Westboro Road, North Grafton, MA 01536, USA
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Studer KA, Hanzlicek A, Di Girolamo N, Womble W, Pathak D, Maranville R, Kanda I, Brandão J. Effect of rest temperature on rotational thromboelastometry in New Zealand White rabbits. J Vet Diagn Invest 2020; 33:47-51. [PMID: 33155522 DOI: 10.1177/1040638720968536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
With the increasing popularity of viscoelastic coagulation analyzers, such as rotational thromboelastometry [ROTEM] and thromboelastography, the need for standardized methodology for appropriate interpretation has become increasingly important. Viscoelastic analysis is heavily influenced by a multitude of pre-analytic factors, both in vivo and in vitro, leading to a large amount of variation between institutions. We investigated the effect of room temperature during a 30-min sample rest time on ROTEM, which analyzed both intrinsic and extrinsic pathways. We also evaluated the feasibility of using ROTEM to assess coagulation in non-anesthetized domestic rabbits. Rabbits were selected because they are a common companion animal that could benefit from the use of viscoelastic analysis for various disease processes that could lead to coagulopathies. Citrated whole blood was collected from 10 rabbits and allowed to rest upright for 30 min either at room temperature (~ 21°C) or in a tube warmer (37°C) before analysis. There was no significant difference in results between room temperature and warmed samples, which suggests that allowing samples to rest at room temperature is acceptable clinically. Additionally, blood collection and analysis were feasible in all rabbits.
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Affiliation(s)
- Kelsea A Studer
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - Andrew Hanzlicek
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - Nicola Di Girolamo
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - William Womble
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - Debosree Pathak
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - Rachel Maranville
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - Ian Kanda
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
| | - João Brandão
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Oklahoma State University, Stillwater, OK
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Ahammad J, Kurien A, Shastry S, Shah HH, Nayak D, Kamath A, Badagabettu S. Age‐ and gender‐related reference ranges for thromboelastography from a healthy Indian population. Int J Lab Hematol 2019; 42:180-189. [DOI: 10.1111/ijlh.13148] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 11/18/2019] [Accepted: 12/04/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Javed Ahammad
- Melaka Manipal Medical College Manipal Academy of Higher Education Manipal India
| | - Annamma Kurien
- Melaka Manipal Medical College Manipal Academy of Higher Education Manipal India
| | - Shamee Shastry
- Kasturba Medical College Manipal Academy of Higher Education Manipal India
| | - Hitesh H. Shah
- Kasturba Medical College Manipal Academy of Higher Education Manipal India
| | - Dinesh Nayak
- Melaka Manipal Medical College Manipal Academy of Higher Education Manipal India
| | - Asha Kamath
- Department of Statistics Manipal Academy of Higher Education Manipal India
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Pharmacokinetics and pharmacodynamics of SCT800, a new recombinant FVIII, in hemophilia A mice. Acta Pharmacol Sin 2016; 37:408-14. [PMID: 26806305 DOI: 10.1038/aps.2015.121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 08/26/2015] [Indexed: 01/31/2023] Open
Abstract
AIM SCT800 is a new third-generation recombinant FVIII agent that is undergoing promising preclinical study. This study aimed to investigate the pharmacokinetic and pharmacodynamic profiles of SCT800 in hemophilia A mice. METHODS After hemophilia A mice were intravenously injected with single dose of SCT800 (80, 180, and 280 IU/kg) or the commercially available product Xyntha (280 IU/kg), pharmacokinetics profiles were evaluated based on measuring plasma FVIII C. For pharmacodynamics study, dose-response curves of SCT800 and Xyntha (1-200 IU/kg) were constructed using a tail bleeding model monitoring both bleeding time and blood loss. RESULTS Pharmacokinetics profile analysis showed a dose independency of SCT800 ranging from 80 to 280 IU/kg and comparable pharmacokinetic profiles between SCT800 and Xyntha at the doses tested. Pharmacodynamics study revealed comparable ED50 values of SCT800 and Xyntha in the tail bleeding model: 14.78 and 15.81 IU/kg for bleeding time, respectively; 13.50 and 13.58 IU/kg for blood loss, respectively. Moreover, at the doses tested, the accompanying dose-related safety evaluation in the tail bleeding model showed lower hypercoagulable tendency and wider dosage range potential for SCT800 than Xyntha. CONCLUSION In hemophilia A mice, SCT800 shows comparable pharmacokinetics and pharmacodynamics to Xyntha at the doses tested, and possibly with better safety properties.
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Burggraf M, Payas A, Kauther MD, Schoeneberg C, Lendemans S. Evaluation of clotting factor activities early after severe multiple trauma and their correlation with coagulation tests and clinical data. World J Emerg Surg 2015; 10:43. [PMID: 26396589 PMCID: PMC4578761 DOI: 10.1186/s13017-015-0038-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 09/15/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Traumatic injuries are amongst the leading causes of death worldwide, frequently as a result of uncontrolled hemorrhage. Critical deficiencies in clotting factors have been noted in trauma-induced coagulopathy. However, the exact underlying conditions that result in devastating coagulopathies remain unclear. The purpose of this study was to elucidate these underlying deficiencies. METHODS Blood samples were drawn from 45 severely injured trauma patients on their arrival at the resuscitation room, and the activities of all soluble clotting factors and routine coagulation tests were assessed. The Mann-Whitney-U-test was used to assess differences in coagulation activity between the patients and healthy controls. Furthermore, Spearman's rank correlation was used to analyze the blood work. RESULTS After severe trauma the levels of serum fibrinogen and calcium were significantly reduced. Furthermore, traumatized patients had a significantly increased International Normalized Ratio (INR) compared to healthy controls. The median activities of all clotting factors were reduced after severe multiple trauma, with the exception of factor VIII, which was increased. Statistically significant differences were observed for factors II (80 vs. 122 %, P < 0.0001), V (76 vs. 123 %, P < 0.0001), VII (90 vs. 114 %, P = 0.002), VIII (200 vs. 108 %, P < 0.0001), and X (86 vs. 122 %, P < 0.0001). Spearman's correlation indicated a significant negative correlation between INR on arrival with fibrinogen and levels of factors II, V, and VII, whereas Partial Thromboplastin Time was significantly negatively correlated with factor VIII (all P < 0.0001). CONCLUSIONS These findings suggest a general but rather moderate impairment of clotting factor activities following severe multiple trauma. In the concept of a calculated coagulation therapy, this could demand for the use of factor concentrates with higher ratios of clotting factors. Finally, the physiological importance of strongly elevated factor VIII activity remains unclear, but a possible interference with ex vivo measurements of Partial Thromboplastin Time has to be considered.
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Affiliation(s)
- Manuel Burggraf
- Department for Orthopaedics and Emergency Surgery, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Arzu Payas
- Department for Orthopaedics and Emergency Surgery, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Max Daniel Kauther
- Department for Orthopaedics and Emergency Surgery, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Carsten Schoeneberg
- Clinic for Accident Surgery and Orthopaedics, Alfried Krupp Hospital Steele, Hellweg 100, 45276 Essen, Germany
| | - Sven Lendemans
- Clinic for Accident Surgery and Orthopaedics, Alfried Krupp Hospital Steele, Hellweg 100, 45276 Essen, Germany
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All the bang without the bucks: Defining essential point-of-care testing for traumatic coagulopathy. J Trauma Acute Care Surg 2015; 79:117-24; discussion 124. [PMID: 26091324 DOI: 10.1097/ta.0000000000000691] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Rapid assessment and treatment of coagulopathy reduces postinjury morbidity and mortality. Although thrombelastography (TEG) may be more accurate and efficient than conventional coagulation tests, it requires significant financial and personnel investments. We hypothesized that point-of-care international normalized ratio (POC INR) may provide a rapid and accurate alternative to TEG. METHODS A retrospective review of sequential trauma patients who underwent both POC INR and rapid TEG (r-TEG) testing upon presentation to a Level I trauma center from July 2012 to December 2013 was performed. POC INR was compared with r-TEG values (R value, K time, α angle, maximum amplitude, percent clot lysis in 30 minutes) and transfusion requirements. Vital signs, admission laboratory values, and injury severity were analyzed. POC INR and venous blood gas testing was performed in the emergency department. All results and Pearson correlations noted were significant if p < 0.05. RESULTS We identified 628 trauma patients with concomitant r-TEG and POC INR testing. Median Injury Severity Score (ISS) was 13, 20% arrived in shock (base value < -5), 21% were transfused, and 11% died. POC INR correlated with all r-TEG values, with stronger correlations for patients in shock. POC INR and r-TEG had similar correlations with blood products transfused at 4 hours and 24 hours, but only POC INR predicted substantial bleeding and massive transfusion. POC INR also correlated strongly with standard INR testing. POC INR test duration was less than 1 minute, compared with at least 30 minutes for r-TEG. Total cohort charges for POC INR were estimated at $21,980 versus $396,896 for r-TEG. CONCLUSION POC INR testing is faster and cheaper than r-TEG. In addition, POC INR correlates not only with r-TEG values but also with acute blood product transfusions. POC INR provides a practical alternative for rapid coagulopathy assessment in the trauma patient at institutions that lack TEG capability. LEVEL OF EVIDENCE Diagnostic study, level III. Therapeutic/care management study, level IV.
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Spronk HMH, Braunschweig T, Rossaint R, Wüst DC, van Oerle R, Lauritzen B, Tolba R, Grottke O. Recombinant Factor VIIa Reduces Bleeding after Blunt Liver Injury in a Pig Model of Dilutional Coagulopathy under Severe Hypothermia. PLoS One 2015; 10:e0113979. [PMID: 26098426 PMCID: PMC4476676 DOI: 10.1371/journal.pone.0113979] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 10/31/2014] [Indexed: 11/29/2022] Open
Abstract
Background Recombinant factor VIIa (rFVIIa) is registered for use in haemophilia with inhibitors and other rare bleeding disorders, but has also been used in various other clinical conditions to terminate life-threatening bleeding. Underlying conditions (e.g. coagulopathy) and dosing may affect treatment efficacy. The objective of the present study was to evaluate the impact of increasing doses of rFVIIa on blood loss and coagulation assays in haemodiluted and hypothermic pigs undergoing blunt liver injury. Methods A grade III blunt liver injury was induced in 28 pigs after 70% haemodilution and cooling to 32.6–33.4°C. Ten minutes after trauma, animals randomly received placebo or 90, 180 or 360 μg/kg rFVIIa. Global coagulation parameters, thromboelastometry (TEM) and plasma thrombin generation (TG) were determined at different time points during the observation period of 120 minutes. Results Total blood loss was significantly lower following 90 μg/kg rFVIIa (1206 [1138–1470] mL) relative to placebo (2677 [2337–3068] mL; p<0.05), with no increased effect with higher dose levels of rFVIIa. Following trauma and haemodilution, coagulation was impaired relative to baseline in both TEM and TG analysis. At 60 and 120 minutes after trauma, TEM variables improved in the rFVIIa-treated animals compared with the placebo group. Similarly, rFVIIa improved coagulation kinetics in TG. As was observed with blood loss, no significant effect between different rFVIIa dose levels was found in TEM or TG. Macro- and microscopic post-mortem examination did not reveal any signs of thromboembolic events. Conclusion Early administration of 90 μg/kg rFVIIa reduced blood loss in pigs undergoing blunt liver injury even after severe haemodilution and hypothermia, with no further effect of higher dose levels. Coagulation assays showed impaired coagulation in coagulopathic animals, with a dose-independent improvement in animals treated with rFVIIa.
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Affiliation(s)
- Henri M. H. Spronk
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Till Braunschweig
- Department of Pathology, RWTH Aachen University Hospital, Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Dirk C. Wüst
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Rene van Oerle
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | | | - Rene Tolba
- Institute for Laboratory Animal Science, RWTH Aachen University Hospital, Aachen, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
- * E-mail:
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Obesity and clotting: Body mass index independently contributes to hypercoagulability after injury. J Trauma Acute Care Surg 2015; 78:30-6; discussion 37-8. [PMID: 25539200 DOI: 10.1097/ta.0000000000000490] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although obese patients have high thrombosis rates following injury, the role of obesity in coagulation after trauma remains unknown. We hypothesized that body mass index (BMI) is independently associated with increased measures of hypercoagulability longitudinally after injury. METHODS Data were prospectively collected for 377 consecutive highest-level trauma activation patients with a BMI of 18.5 kg/m² or greater. Standard coagulation measures, citrated kaolin and functional fibrinogen thromboelastography, as well as clotting factors were measured at 0 hour to 120 hours. BMI categories were defined as normal weight (18.5-24.99 kg/m²), overweight (25-29.99 kg/m²), and obese (≥30 kg/m²). RESULTS The 377 patients were mostly male (81%) and had blunt injury (61%), with a median BMI of 25.8 kg/m². Of the patients, 42% were normal weight (median BMI, 22.5 kg/m²). There were no differences in age, sex, Injury Severity Score (ISS), or base deficit between groups. There were no differences in admission international normalized ratio/partial thromboplastin time or factors II, V, VII, VIII, and X; antithrombin III; or protein C. However, obese patients had higher admission platelet counts (303 × 10⁹/L vs. 269 × 10⁹/L, p = 0.004), lower D-dimer (1.88 μg/mL vs. 4.00 μg/mL, p = 0.004), and a trend toward higher factor IX (134% vs. 119% activity, p = 0.042) compared with normal weight patients. Measured by thromboelastography, clot strength (maximum amplitude) and functional fibrinogen level (FLEV) were also higher on admission for obese patients (maximum amplitude, 65.7 mm vs. 63.4 mm, p = 0.016; FLEV, 407 mg/dL vs. 351 mg/dL, p = 0.008). In multiple linear regression, the relationship of BMI to clot strength, FLEV, and factor IX persisted through 24 hours. Similarly, the relationship of BMI and platelet count persisted through 120 hours (all p < 0.05). In multiple logistic regression, for every 5-kg/m² increase in BMI, there was an 85% increase in odds of thromboembolic complication (odds ratio, 1.85; 95% confidence interval, 1.13-3.08; p = 0.017). CONCLUSION Obese trauma patients are hypercoagulable compared with their similarly injured normal-weight counterparts, which persists longitudinally after injury. The significance of this hypercoagulability requires elucidation for guidance of anticoagulation in this at-risk group. LEVEL OF EVIDENCE Prognostic study, level III.
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Fibrinogen and platelet contributions to clot formation: implications for trauma resuscitation and thromboprophylaxis. J Trauma Acute Care Surg 2014; 76:255-6; discussion 262-3. [PMID: 24458031 DOI: 10.1097/ta.0000000000000108] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Thromboelastography (TEG) is used to diagnose perturbations in clot formation and lysis that are characteristic of acute traumatic coagulopathy. With novel functional fibrinogen (FF) TEG, fibrin- and platelet-based contributions to clot formation can be elucidated to tailor resuscitation and thromboprophylaxis. We sought to describe the longitudinal contributions of fibrinogen and platelets to clot strength after injury, hypothesizing that low levels of FF and a low contribution of fibrinogen to clot strength on admission would be associated with coagulopathy, increased transfusion requirements, and worse outcomes. METHODS A total of 603 longitudinal plasma samples were prospectively collected from 251 critically injured patients at a single Level 1 trauma center from 0 hour to 120 hours. TEG maximal amplitude (MA), FF MA, FF levels, von Clauss fibrinogen, and standard coagulation measures were performed in parallel. Percentage contributions of FF (%MA(FF)) and platelets (%MA(platelets)) were calculated as each MA divided by overall kaolin TEG MA. RESULTS Coagulopathic patients (international normalized ratio ≥ 1.3) had significantly lower admission %MA(FF) than noncoagulopathic patients (24.7% vs. 31.2%, p < 0.05). Patients requiring plasma transfusion had a significantly lower admission %MA(FF) (26.6% vs. 30.6%, p < 0.05). Higher admission %MA(FF) was predictive of reduced mortality (hazard ratio, 0.815, p < 0.001). %MA(platelets) was higher than %MA(FF) at all time points, decreased over time, and stabilized at 72 hours (69.4% at 0 hour, 56.2% at 72 hours). In contrast, %MA(FF) increased over time and stabilized at 72 hours (30.6% at 0 hour, 43.8% at 72 hours). CONCLUSION FF TEG affords differentiation of fibrin- versus platelet-based clot dynamics. Coagulopathy and plasma transfusion were associated with a lower %MA(FF). Despite this importance of fibrinogen, platelets had a greater contribution to clot strength at all time points after injury. This suggests that attention to these relative contributions should guide resuscitation and thromboprophylaxis and that antiplatelet therapy may be of underrecognized importance to thromboprophylaxis after trauma. LEVEL OF EVIDENCE Prognostic study, level III.
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Whelihan MF, Kiankhooy A, Brummel-Ziedins KE. Thrombin generation and fibrin clot formation under hypothermic conditions: an in vitro evaluation of tissue factor initiated whole blood coagulation. J Crit Care 2013; 29:24-30. [PMID: 24331944 DOI: 10.1016/j.jcrc.2013.10.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 09/06/2013] [Accepted: 10/20/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite trauma-induced hypothermic coagulopathy being familiar in the clinical setting, empirical experimentation concerning this phenomenon is lacking. In this study, we investigated the effects of hypothermia on thrombin generation, clot formation, and global hemostatic functions in an in vitro environment using a whole blood model and thromboelastography, which can recapitulate hypothermia. METHODS Blood was collected from healthy individuals through venipuncture and treated with corn trypsin inhibitor, to block the contact pathway. Coagulation was initiated with 5pM tissue factor at temperatures 37°C, 32°C, and 27°C. Reactions were quenched over time, with soluble and insoluble components analyzed for thrombin generation, fibrinogen consumption, factor (f)XIII activation, and fibrin deposition. Global coagulation potential was evaluated through thromboelastography. RESULTS Data showed that thrombin generation in samples at 37°C and 32°C had comparable rates, whereas 27°C had a much lower rate (39.2 ± 1.1 and 43 ± 2.4 nM/min vs 28.6 ± 4.4 nM/min, respectively). Fibrinogen consumption and fXIII activation were highest at 37°C, followed by 32°C and 27°C. Fibrin formation as seen through clot weights also followed this trend. Thromboelastography data showed that clot formation was fastest in samples at 37°C and lowest at 27°C. Maximum clot strength was similar for each temperature. Also, percent lysis of clots was highest at 37°C followed by 32°C and then 27°C. CONCLUSIONS Induced hypothermic conditions directly affect the rate of thrombin generation and clot formation, whereas global clot stability remains intact.
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Affiliation(s)
- Matthew F Whelihan
- Departments of Biochemistry and Surgery, College of Medicine, University of Vermont, Burlington, VT.
| | - Armin Kiankhooy
- Departments of Biochemistry and Surgery, College of Medicine, University of Vermont, Burlington, VT.
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Functional fibrinogen assay indicates that fibrinogen is critical in correcting abnormal clot strength following trauma. Shock 2013; 39:45-9. [PMID: 23247121 DOI: 10.1097/shk.0b013e3182787122] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thromboelastography (TEG) is emerging as the standard in the management of acute coagulopathies in injured patients. Although TEG is sensitive in detecting abnormalities in clot strength, one shortcoming is differentiating between fibrinogen and platelet contributions to clot integrity. Current American algorithms suggest platelet transfusion, whereas European guidelines suggest fibrinogen concentrates for correcting low clot strength. Therefore, we hypothesized that a TEG-based functional fibrinogen (FF) assay would assess the contribution of fibrinogen and platelets to clot strength and provide insight to transfusion priorities. Blood samples were obtained from trauma patients on arrival to the emergency department or who were admitted to the surgical intensive care unit (n = 68). Citrated kaolin TEG, FF, and von Clauss fibrinogen levels (plasma-based clinical standard) were measured. Correlations were assessed using linear regression models. In vitro studies were also performed with adding fibrinogen concentrates to blood collected from healthy volunteers (n = 10). Functional fibrinogen and citrated kaolin TEG parameters were measured. Functional fibrinogen strongly correlated with von Clauss fibrinogen levels (R = 0.87) and clot strength (R = 0.80). The mean fibrinogen contribution to clot strength was 30%; however, there was a direct linear relationship with fibrinogen level and percent fibrinogen contribution to clot strength (R = 0.83). Traditional TEG parameters associated with fibrinogen activity (α angle and kinetic time) had significantly lower correlations with FF (R = 0.70 and 0.35). Furthermore, platelet count had only a moderate correlation to clot strength (R = 0.51). The addition of fibrinogen concentrate in in vitro studies increased clot strength (MA) (60.44 ± 1.48 to 68.12 ± 1.39) and percent fibrinogen contribution to clot strength (23.8% ± 1.8% to 37.7% ± 2.5%). Functional fibrinogen can be performed rapidly with TEG and correlates well with the standard von Clauss fibrinogen assay. Both fibrinogen and platelet contribution of clot strength can be derived from FF. Moreover, FF had a stronger correlation to clot strength, and increased levels were directly associated with increased percent contribution to clot strength. In vitro studies also demonstrated an increase in FF, clot strength, and percent fibrinogen contribution to clot strength with the addition of fibrinogen concentrate. These data suggest that fibrinogen should be addressed early in trauma patients manifesting acute coagulopathy of trauma.
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Vogel AM, Radwan ZA, Cox CS, Cotton BA. Admission rapid thrombelastography delivers real-time "actionable" data in pediatric trauma. J Pediatr Surg 2013; 48:1371-6. [PMID: 23845632 DOI: 10.1016/j.jpedsurg.2013.03.036] [Citation(s) in RCA: 159] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 03/08/2013] [Indexed: 12/12/2022]
Abstract
PURPOSE Admission rapid thrombelastography (rTEG) is a "real-time" clinical tool used to evaluate trauma-induced coagulopathy and direct hemostatic resuscitation. The relationship of rTEG to conventional coagulation tests (CCT) and early lifesaving interventions (LSI) in pediatric trauma is unknown. METHODS Severely injured patients (age ≤ 14 years) with an rTEG were retrospectively reviewed (8/1/2009-8/31/2011). Demographic and clinical information was collected. Spearman's correlation and regression models were used to evaluate rTEG with respect to CCT, early transfusion, LSI, and mortality. RESULTS Eighty-six patients were identified. The median age was 8 years, and the median injury severity score (ISS) was 21. Activated clotting time (r=0.68), k-time (r=0.77), and α-angle (r=-0.75) showed strong correlation to PTT, and maximum amplitude (MA) (r=0.46) showed good correlation to platelet count (all p<0.001). When controlling for age, gender, and ISS, regression analysis showed that ACT, r-value, k-time, α-angle, and MA predicted red blood cell and plasma transfusion within 6h. MA (OR 0.82, 95% CI 0.70-0.96; p=0.018) was predictive of LSI. All rTEG values, except for LY30, predicted mortality. CONCLUSION Admission rTEG correlates with CCT and predicts early transfusion, early LSI, and outcome in pediatric trauma. rTEG provides valuable data for goal-directed hemostatic resuscitation of critically injured children.
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Affiliation(s)
- Adam M Vogel
- Division of Pediatric Surgery, Washington University in Saint Louis School of Medicine, St. Louis, MO 63110, USA.
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Admission Rapid Thrombelastography Can Replace Conventional Coagulation Tests in the Emergency Department. Ann Surg 2012; 256:476-86. [DOI: 10.1097/sla.0b013e3182658180] [Citation(s) in RCA: 313] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Freire DF, Taha MO, Soares JH, Simões MDJ, Fagundes ALN, Fagundes DJ. The laparoscopy splenic injury repair: the use of fibrin glue in a heparinized porcine model. Acta Cir Bras 2012; 26:235-41. [PMID: 21537527 DOI: 10.1590/s0102-86502011000300013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To investigate the effectiveness of fibrin glue (laparoscopic via) into promote the hemostasis of a spleen injury on a heparinized porcine model. METHODS Eighteen Landrace porcine were submitted to laparoscopic spleen injury and randomly distributed: GHA (heparin plus adhesive), GH (heparin without adhesive) and GS (Sham - without heparin or adhesive). Ten minutes before the surgical procedures a single IV dose (200UI/kg) of heparin sodium was administrated only to groups GHA and GH. In the GHA, adhesive was applied after the mechanical injury and recorded the time until the polymerization and clot formation. RESULTS No significant differences occurred among the groups (Fisher test) considering the weight and surgery time. The blood amount in the abdominal cavity on GH was significantly higher in comparison to the sham group and especially with the GHA (p<0.004). No significant differences were observed in the body temperature, heart rate, cardiac output, means arterial pressure, pulmonary artery pressure during the experiment. The activated partial thromboplastin time (APTT) was lower in the GHA in comparison to GH (p<0.003). CONCLUSION The fibrin biological adhesive applied by laparoscopy is effective for hemostasis of minor spleen injury in a porcine model under the effect of anticoagulant drug.
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Taggart R, Austin B, Hans E, Hogan D. In vitro evaluation of the effect of hypothermia on coagulation in dogs via thromboelastography. J Vet Emerg Crit Care (San Antonio) 2012; 22:219-24. [DOI: 10.1111/j.1476-4431.2012.00729.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Mitrophanov AY, Rosendaal FR, Reifman J. Computational analysis of intersubject variability and thrombin generation in dilutional coagulopathy. Transfusion 2012; 52:2475-86. [PMID: 22429019 DOI: 10.1111/j.1537-2995.2012.03610.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Blood dilution is a frequent complication of massive transfusion during trauma and surgery. This article investigates the quantitative effects of blood plasma dilution on thrombin generation in the context of intersubject variability. STUDY DESIGN AND METHODS A thoroughly validated computational model was used to simulate thrombin generation curves for 472 healthy subjects in the Leiden Thrombophilia Study. Individual thrombin curves were calculated for undiluted blood and for different dilution scenarios. For every such curve, five standard quantitative parameters of thrombin generation were calculated and analyzed. RESULTS Thrombin generation parameters in diluted blood plasma displayed significant intersubject variability (with a coefficient of variation up to approx. 28%). Nevertheless, dilutional effects in the majority (or all) of the subjects in the study group were characterized by persistent patterns. In particular, the largest dilution-induced change typically occurred in the maximum slope (MS) of the thrombin curve, followed by a change in thrombin peak height (PH), whereas the smallest change often occurred in the area under the curve. The identified patterns demonstrated considerable robustness to variations in dilution scenario and tissue factor concentration. CONCLUSION Dilutional effects on thrombin generation in a human population can be predicted from trends identified for the "average" subject and then refined by performing an analysis of actual subjects in the study group. The MS and PH are dilution indicators that are both sensitive and reliable across a large subject group and could potentially be used as disease markers in the diagnosis of coagulopathic conditions.
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Affiliation(s)
- Alexander Y Mitrophanov
- DoD Biotechnology High-Performance Computing Software Applications Institute, Telemedicine and Advanced Technology Research Center, US Army Medical Research and Materiel Command, Ft Detrick, Maryland 21702, USA.
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Abstract
BACKGROUND Coagulopathic bleeding is a leading cause of in-hospital death after injury. A recently proposed transfusion strategy calls for early and aggressive frozen plasma transfusion to bleeding trauma patients, thus addressing trauma-associated coagulopathy (TAC) by transfusing clotting factors (CFs). This strategy may dramatically improve survival of bleeding trauma patients. However, other studies suggest that early TAC occurs by protein C activation and is independent of CF deficiency. This study investigated whether CF deficiency is associated with early TAC. METHODS This is a prospective observational cohort study of severely traumatized patients (Injury Severity Score ≥ 16) admitted shortly after injury, receiving minimal fluids and no prehospital blood. Blood was assayed for CF levels, thromboelastography, and routine coagulation tests. Critical CF deficiency was defined as ≤ 30% activity of any CF. RESULTS Of 110 patients, 22 (20%) had critical CF deficiency: critically low factor V level was evident in all these patients. International normalized ratio, activated prothrombin time, and, thromboelastography were abnormal in 32%, 36%, and 35%, respectively, of patients with any critically low CF. Patients with critical CF deficiency suffered more severe injuries, were more acidotic, received more blood transfusions, and showed a trend toward higher mortality (32% vs. 18%, p = 0.23). Computational modeling showed coagulopathic patients had pronounced delays and quantitative deficits in generating thrombin. CONCLUSIONS Twenty percent of all severely injured patients had critical CF deficiency on admission, particularly of factor V. The observed factor V deficit aligns with current understanding of the mechanisms underlying early TAC. Critical deficiency of factor V impairs thrombin generation and profoundly affects hemostasis.
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The role of thrombelastography in multiple trauma. Emerg Med Int 2011; 2011:895674. [PMID: 22046550 PMCID: PMC3200213 DOI: 10.1155/2011/895674] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 07/07/2011] [Indexed: 11/18/2022] Open
Abstract
Hemorrhage and traumatic coagulopathyis are major causes of early death in multiply injured patients. Thrombelastography (TEG) seems to be a fast and accurate coagulation test in trauma care. We suggest that multiply injured trauma patients would benefit the most from an early assessment of coagulation by TEG, mainly RapidTEG, to detect an acute traumatic coagulopathy and especially primary fibrinolysis, which is related with high mortality. This review gives an overview on TEG and its clinical applications.
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Nascimento B, Al Mahoos M, Callum J, Capone A, Pacher J, Tien H, Rizoli S. Vitamin K-dependent coagulation factor deficiency in trauma: a comparative analysis between international normalized ratio and thromboelastography (CME). Transfusion 2011; 52:7-13. [DOI: 10.1111/j.1537-2995.2011.03237.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Midwinter MJ, Woolley T. Resuscitation and coagulation in the severely injured trauma patient. Philos Trans R Soc Lond B Biol Sci 2011; 366:192-203. [PMID: 21149355 DOI: 10.1098/rstb.2010.0220] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Developments in the resuscitation of the severely injured trauma patient in the last decade have been through the increased understanding of the early pathophysiological consequences of injury together with some observations and experiences of recent casualties of conflict. In particular, the recognition of early derangements of haemostasis with hypocoagulopathy being associated with increased mortality and morbidity and the prime importance of tissue hypoperfusion as a central driver to this process in this population of patients has led to new resuscitation strategies. These strategies have focused on haemostatic resuscitation and the development of the ideas of damage control resuscitation and damage control surgery continuum. This in turn has led to a requirement to be able to more closely monitor the physiological status, of major trauma patients, including their coagulation status, and react in an anticipatory fashion.
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Affiliation(s)
- Mark J Midwinter
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Midwinter MJ. Damage control surgery in the era of damage control resuscitation. J ROY ARMY MED CORPS 2011; 155:323-6. [PMID: 20397611 DOI: 10.1136/jramc-155-04-16] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Gonzalez E, Pieracci FM, Moore EE, Kashuk JL. Coagulation abnormalities in the trauma patient: the role of point-of-care thromboelastography. Semin Thromb Hemost 2010; 36:723-37. [PMID: 20978993 PMCID: PMC4369086 DOI: 10.1055/s-0030-1265289] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Current recommendations for resuscitation of the critically injured patient are limited by a lack of point-of-care (POC) assessment of coagulation status. Accordingly, the potential exists for indiscriminant blood component administration. Furthermore, although thromboembolic events have been described shortly after injury, the time sequence of post-injury coagulation changes is unknown. Our current understanding of hemostasis has shifted from a classic view, in which coagulation was considered a chain of catalytic enzyme reactions, to the cell-based model (CBM), representing the interplay between the cellular and plasma components of clot formation. Thromboelastography (TEG), a time-sensitive dynamic assay of the viscoelastic properties of blood, closely parallels the CBM, permitting timely, goal-directed restoration of hemostasis via POC monitoring of coagulation status. TEG-based therapy allows for goal-directed blood product administration in trauma, with potential avoidance of the complications resulting from overzealous component administration, as well as the ability to monitor post-injury coagulation status and thromboprophylaxis. This overview addresses coagulation status and thromboprophylaxis management in the trauma patient and the emerging role of POC TEG.
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Affiliation(s)
- Eduardo Gonzalez
- Department of Surgery, Denver Health Medical Center and University of Colorado School of Medicine, Denver, Colorado
| | - Fredric M. Pieracci
- Department of Surgery, Denver Health Medical Center and University of Colorado School of Medicine, Denver, Colorado
| | - Ernest E. Moore
- Department of Surgery, Denver Health Medical Center and University of Colorado School of Medicine, Denver, Colorado
| | - Jeffry L. Kashuk
- Department of Surgery, Division of Acute Care Surgery, Penn State-Hershey College of Medicine, Hershey, Pennsylvania
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Sharma P, Saxena R. A novel thromboelastographic score to identify overt disseminated intravascular coagulation resulting in a hypocoagulable state. Am J Clin Pathol 2010; 134:97-102. [PMID: 20551273 DOI: 10.1309/ajcppz4j6cafydvm] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Thromboelastography (TEM) yields a multitude of data that are complicated to analyze. We evaluated its value in identification of global coagulopathy in overt disseminated intravascular coagulation (DIC). We studied 21 patients, each with International Society for Haemostasis and Thrombosis scores of 5 or more (compatible with overt DIC) and less than 5 (suggestive of nonovert DIC), who underwent whole blood nonadditive TEM. A TEM score based on the reaction and kappa times, alpha angle, and maximum amplitude was defined as the total number of TEM parameters deranged in the direction of hypocoagulability. The TEM score at a cutoff of 2 or more achieved sensitivity of 95.2%, specificity of 81.0%, and the highest receiver operating characteristic area under the curve of all parameters of 0.957 for identifying overt DIC. Individual TEM parameters correlated variably with conventional tests. Their combination into a cohesive TEM score possibly better captured the multiple hemostatic derangements occurring in DIC. The TEM score may bring objectivity to the analysis of TEM data.
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Tisherman SA. Is fibrinogen the answer to coagulopathy after massive transfusions? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:154. [PMID: 20497599 PMCID: PMC2911703 DOI: 10.1186/cc9000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Coagulopathy is a major cause of morbidity and mortality in patients who have suffered severe hemorrhage and received massive transfusions. Administration of a fibrinogen concentrate along with red blood cells can quickly restore hemostasis in a clinically relevant animal model.
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Affiliation(s)
- Samuel A Tisherman
- Departments of Critical Care Medicine and Surgery, University of Pittsburgh, 638 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA.
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Abstract
Multiple trauma patients frequently demonstrate a hypothermic core temperature, defined as a temperature below 35 degrees C, already at admission in the emergency room. As a drop of the core temperature below 34 degrees C has been shown to be associated with a significant increase in post-traumatic complications, this limit is considered to be critical in these patients. Multiple trauma patients with hypothermia demonstrate a markedly increased mortality rate compared to normothermic patients with the same injury severity. Therefore effective rewarming measures are essential for adequate bleeding control and successful resuscitation. If and to what extent the induction of controlled hypothermia in the early phase of treatment on the intensive care unit after resuscitation and operative bleeding control can contribute to an improved post-traumatic outcome, has to be clarified in further experimental and clinical studies.
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Hypocoagulability, as evaluated by thrombelastography, at admission to the ICU is associated with increased 30-day mortality. Blood Coagul Fibrinolysis 2010; 21:168-74. [PMID: 20051844 DOI: 10.1097/mbc.0b013e3283367882] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thrombelastography (TEG), a cell-based whole blood assay, may better reflect haemostatic competence than conventional coagulation assays and this was therefore evaluated including the clot forming parameters: R, angle and maximal amplitude in patients at ICU admission. This was a prospective, observational study of patients admitted to a general ICU at a tertiary care university hospital with an expected stay of more than 24 h. Blood samples for TEG and standard coagulation analysis were obtained at admission. The APACHE II and sequential organ failure assessment (SOFA) scores and 30-day mortality were recorded. At ICU admission, 106 patients (42%) showed hypocoagulability as evaluated by TEG and these patients had higher first day SOFA score (P < 0.0001) and higher 30-days (42 vs. 13%, P < 0.0001) mortality than patients presenting with a normal TEG. In 30-day survivors, admission platelet count (P = 0.05), angle (P < 0.001) and maximal amplitude (P = 0.001) were higher and R decreased (P = 0.0013) compared with nonsurvivors. Hypocoagulability at admission as evaluated by TEG was an independent risk factor for 30-day mortality [adjusted odds ratio (OR) 3.5; 95% confidence interval (CI) 1.7-7.1]. Hypocoagulability as evaluated by TEG was frequent at admission in general ICU patients and associated with a higher rate of ventilator treatment, higher rate of renal replacement therapy and a higher use of blood products. Hypocoagulability is an independent risk factor for 30-day mortality.
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Grottke O, Braunschweig T, Henzler D, Coburn M, Tolba R, Rossaint R. Effects of different fibrinogen concentrations on blood loss and coagulation parameters in a pig model of coagulopathy with blunt liver injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R62. [PMID: 20398253 PMCID: PMC2887184 DOI: 10.1186/cc8960] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 03/09/2010] [Accepted: 04/14/2010] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The early application of fibrinogen could potentially reverse haemodilution-induced coagulopathy, although the impact of varying concentrations of fibrinogen to reverse dilutional coagulopathy has not been studied in vivo. We postulated that fibrinogen concentration is correlated with blood loss in a pig model of coagulopathy with blunt liver injury. METHODS Coagulopathy was induced in 18 anaesthetized pigs (32 +/- 1.6 kg body weight) by replacing 80% of blood volume with hydroxyethylstarch 130/0.4 and Ringer's lactated solution, and re-transfusion of erythrocytes. Animals were randomly assigned to receive either 70 mg kg-1 (F-70) or 200 mg kg-1 (F-200) fibrinogen or placebo before inducing blunt liver injury using a force of 225 +/- 26 Newton. Haemodynamics, coagulation parameters and blood loss were monitored for 2 hours. After death, histological examination of internal organs was performed to assess the presence of emboli and the equality of liver injury. RESULTS Plasma dilution caused severe coagulopathy. Measured by thromboelastography fibrinogen restored coagulation dose-dependently. Total blood loss was significantly lower and survival better in both fibrinogen groups as compared to controls (P < 0.05). Between the F-70 (1317 +/- 113 ml) and the F-200 group (1155 +/- 232 ml) no significant difference in total blood loss could be observed, despite improved coagulation parameters in the F-200 group (P < 0.05). Microscopy revealed even injury pattern and no (micro) thrombi for either group. CONCLUSIONS Restoring fibrinogen with 70 or 200 mg kg-1 after severe dilutional coagulopathy safely improved coagulation and attenuated blood loss after experimental blunt liver trauma. The higher dosage of fibrinogen was not associated with a further reduction in blood loss.
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Affiliation(s)
- Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital Pauwelsstrasse 30, Aachen, Germany.
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Schöchl H, Nienaber U, Hofer G, Voelckel W, Jambor C, Scharbert G, Kozek-Langenecker S, Solomon C. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R55. [PMID: 20374650 PMCID: PMC2887173 DOI: 10.1186/cc8948] [Citation(s) in RCA: 461] [Impact Index Per Article: 32.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Revised: 01/29/2010] [Accepted: 04/07/2010] [Indexed: 01/18/2023]
Abstract
Introduction The appropriate strategy for trauma-induced coagulopathy management is under debate. We report the treatment of major trauma using mainly coagulation factor concentrates. Methods This retrospective analysis included trauma patients who received ≥ 5 units of red blood cell concentrate within 24 hours. Coagulation management was guided by thromboelastometry (ROTEM®). Fibrinogen concentrate was given as first-line haemostatic therapy when maximum clot firmness (MCF) measured by FibTEM (fibrin-based test) was <10 mm. Prothrombin complex concentrate (PCC) was given in case of recent coumarin intake or clotting time measured by extrinsic activation test (EXTEM) >1.5 times normal. Lack of improvement in EXTEM MCF after fibrinogen concentrate administration was an indication for platelet concentrate. The observed mortality was compared with the mortality predicted by the trauma injury severity score (TRISS) and by the revised injury severity classification (RISC) score. Results Of 131 patients included, 128 received fibrinogen concentrate as first-line therapy, 98 additionally received PCC, while 3 patients with recent coumarin intake received only PCC. Twelve patients received FFP and 29 received platelet concentrate. The observed mortality was 24.4%, lower than the TRISS mortality of 33.7% (P = 0.032) and the RISC mortality of 28.7% (P > 0.05). After excluding 17 patients with traumatic brain injury, the difference in mortality was 14% observed versus 27.8% predicted by TRISS (P = 0.0018) and 24.3% predicted by RISC (P = 0.014). Conclusions ROTEM®-guided haemostatic therapy, with fibrinogen concentrate as first-line haemostatic therapy and additional PCC, was goal-directed and fast. A favourable survival rate was observed. Prospective, randomized trials to investigate this therapeutic alternative further appear warranted.
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Affiliation(s)
- Herbert Schöchl
- Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital, Dr Franz-Rehrl-Platz 5, Salzburg, Austria.
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Evaluation of coagulation stages of hemorrhaged swine: comparison of thromboelastography and rotational elastometry. Blood Coagul Fibrinolysis 2010; 21:20-7. [PMID: 20010092 DOI: 10.1097/mbc.0b013e32833113e9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) assesses blood viscoelastic properties and clotting kinetics that can be measured by Haemoscope TEG and Pentapharm ROTEM devices using slightly different methodologies. These devices were compared by measuring blood samples associated with various degrees of coagulopathy. Blood samples, collected from swine undergoing three types of severe injury and resuscitation protocol resulting in normal, hypercoagulopathy, and hypocoagulopathy, were assessed with TEG or ROTEM before the surgical procedures, and after injury, fluid resuscitation, and simulated hospital phase. Standard clotting parameters were compared by Student's t-test at a significance of a P value less than 0.05. Regression analysis indicated a positive correlation between TEG and ROTEM for reaction time (R), clotting rate (K), and maximum amplitude (Ma) parameters. With samples of normal coagulation, R (440 +/- 136 vs. 391 +/- 73 s), K (99 +/- 39 vs. 81 +/- 20 s), and Ma (74 +/- 4 vs. 69 +/- 5 mm) were higher, whereas (alpha) (68 +/- 8 vs. 75 +/- 3 mm) was lower with TEG than ROTEM, respectively; a P value is less than 0.05. The magnitude of changes from baseline in hypercoagulable or hypocoagulable samples due to level of injury was equivalent with TEG and ROTEM indicating comparable use of the instruments. However, when samples were extremely hypocoagulopathic due to resuscitation fluid, the TEG values could not be readily determined. Overall, TEG readings were higher than ROTEM readings; this disparity between the two instruments was attenuated with hypercoaguable samples. Both devices yielded similar information regarding the status of coagulation related to trauma. Because of operating characteristics, the same instrument should be used for monitoring the same patient or study.
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Tien HC, Scarpellini S, Callum J, Tremblay L, Rizoli S. Assessing response to changing plasma/red cell ratios in a bleeding trauma patient. Am J Emerg Med 2009; 28:120.e1-5. [PMID: 20006235 DOI: 10.1016/j.ajem.2009.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 04/04/2009] [Accepted: 04/08/2009] [Indexed: 11/17/2022] Open
Abstract
Recent military experience suggests that transfusing fresh frozen plasma and packed red cells in a 1:1 ratio may improve survival in exsanguinating trauma patients. We report the case of a single patient who required massive transfusion after suffering a single gunshot wound. Initially, the patient received FFP:PRBC in 1:2 ratio, but this did not correct laboratory parameters except for INR and clotting factor VII level, which were likely normalized by treatment with recombinant activated factor VII. After receiving FFP:PRBC in a 4:5 ratio, he continued to bleed and his coagulation profile showed no appreciable improvement. In the final phase, he received FFP:PRBC in a 7:5 ratio and his laboratory parameters of coagulopathy normalized, except for factor V level which was improved. He also clinically stopped bleeding.
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Affiliation(s)
- Homer C Tien
- Canadian Forces Health Services, Tory Regional Trauma Centre and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada M4N 3M5.
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Abstract
The transfusion approach to massive hemorrhage has continually evolved since it began in the early 1900s. It started with fresh whole blood and currently consists of virtually exclusive use of component and crystalloid therapy. Recent US military experience has reinvigorated the debate on what the most optimal transfusion strategy is for patients with traumatic hemorrhagic shock. In this review we discuss recently described mechanisms that contribute to traumatic coagulopathy, which include increased anti-coagulation factors and hyperfibrinolysis. We also describe the concept of damage control resuscitation (DCR), an early and aggressive prevention and treatment of hemorrhagic shock for patients with severe life-threatening traumatic injuries. The central tenants of DCR include hypotensive resuscitation, rapid surgical control, prevention and treatment of acidosis, hypothermia, and hypocalcemia, avoidance of hemodilution, and hemostatic resuscitation with transfusion of red blood cells, plasma, and platelets in a 1:1:1 unit ratio and the appropriate use of coagulation factors such as rFVIIa and fibrinogen-containing products (fibrinogen concentrates, cryoprecipitate). Fresh whole blood is also part of DCR in locations where it is available. Additional concepts to DCR since its original description that can be considered are the preferential use of "fresh" RBCs, and when available thromboelastography to direct blood product and hemostatic adjunct (anti-fibrinolytics and coagulation factor) administration. Lastly we discuss the importance of an established massive transfusion protocol to rapidly employ DCR and hemostatic resuscitation principles. While the majority of recent trauma transfusion papers are supportive of these general concepts, there is no Level 1 or 2 data available. Taken together, the preponderance of data suggests that these concepts may significantly decrease mortality in massively transfused trauma patients.
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Affiliation(s)
- Philip C. Spinella
- Associate Professor of Pediatrics, University of Connecticut, Pediatric Intensivist, Department of Pediatrics, Medical Director Surgical Critical Care, Department of Surgery, Connecticut Children’s Medical Center, 282 Washington St., Hartford, CT 06106, United States
| | - John B. Holcomb
- Professor of Surgery, Chief, Division of Acute Care Surgery, Director, Center for Translational Injury Research, University of Texas Health Science Center, 6410 Fannin St., Suite 1100 Houston, TX 77030, United States
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Johansson PI, Stissing T, Bochsen L, Ostrowski SR. Thrombelastography and tromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med 2009; 17:45. [PMID: 19775458 PMCID: PMC2758824 DOI: 10.1186/1757-7241-17-45] [Citation(s) in RCA: 199] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 09/23/2009] [Indexed: 11/14/2022] Open
Abstract
Death due to trauma is the leading cause of lost life years worldwide, with haemorrhage being responsible for 30-40% of trauma mortality and accounting for almost 50% of the deaths the initial 24 h. On admission, 25-35% of trauma patients present with coagulopathy, which is associated with a several-fold increase in morbidity and mortality. The recent introduction of haemostatic control resuscitation along with emerging understanding of acute post-traumatic coagulability, are important means to improve therapy and outcome in exsanguinating trauma patients. This change in therapy has emphasized the urgent need for adequate haemostatic assays to monitor traumatic coagulopathy and guide therapy. Based on the cell-based model of haemostasis, there is emerging consensus that plasma-based routine coagulation tests (RCoT), like prothrombin time (PT) and activated partial thromboplastin time (APTT), are inappropriate for monitoring coagulopathy and guide therapy in trauma. The necessity to analyze whole blood to accurately identify relevant coagulopathies, has led to a revival of the interest in viscoelastic haemostatic assays (VHA) such as Thromboelastography (TEG) and Rotation Thromboelastometry (ROTEM). Clinical studies including about 5000 surgical and/or trauma patients have reported on the benefit of using the VHA as compared to plasma-based assays, to identify coagulopathy and guide therapy. This article reviews the basic principles of VHA, the correlation between the VHA whole blood clot formation in accordance with the cell-based model of haemostasis, the current use of VHA-guided therapy in trauma and massive transfusion (haemostatic control resuscitation), limitations of VHA and future perspectives of this assay in trauma.
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Affiliation(s)
- Pär I Johansson
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
| | - Trine Stissing
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
| | - Louise Bochsen
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
| | - Sisse R Ostrowski
- Section for Transfusion Medicine, Regional Blood Bank, Rigshospitalet, University of Copenhagen, Denmark
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Park MS, Martini WZ, Dubick MA, Salinas J, Butenas S, Kheirabadi BS, Pusateri AE, Vos JA, Guymon CH, Wolf SE, Mann KG, Holcomb JB. Thromboelastography as a better indicator of hypercoagulable state after injury than prothrombin time or activated partial thromboplastin time. THE JOURNAL OF TRAUMA 2009; 67:266-75; discussion 275-6. [PMID: 19667878 PMCID: PMC3415284 DOI: 10.1097/ta.0b013e3181ae6f1c] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate the hemostatic status of critically ill, nonbleeding trauma patients. We hypothesized that a hypercoagulable state exists in patients early after severe injury and that the pattern of clotting and fibrinolysis are similar between burned and nonburn trauma patients. MATERIALS Patients admitted to the surgical or burn intensive care unit within 24 hours after injury were enrolled. Blood samples were drawn on days 0 through 7. Laboratory tests included prothrombin time (PT), activated partial thromboplastin time (aPTT), levels of activated factor XI, D-dimer, protein C percent activity, antithrombin III percent activity, and thromboelastography (TEG). RESULTS Study subjects were enrolled from April 1, 2004, to May 31, 2005, and included nonburn trauma patients (n = 33), burned patients (n = 25), and healthy (control) subjects (n = 20). Despite aggressive thromboprophylaxis, three subjects (2 burned and 1 nonburn trauma patients [6%]) had pulmonary embolism during hospitalization. Compared with controls, all patients had prolonged PT and aPTT (p < 0.05). The rate of clot formation (alpha angle) and maximal clot strength were higher for patients compared with those of controls (p < 0.05), indicating a hypercoagulable state. Injured patients also had lower protein C and antithrombin III percent activities and higher fibrinogen levels (p < 0.05 for all). Activated factor XI was elevated in 38% of patients (control subjects had undetectable levels). DISCUSSION Thromboelastography analysis of whole blood showed that patients were in a hypercoagulable state; this was not detected by plasma PT or aPTT. The high incidence of pulmonary embolism indicated that our current prophylaxis regimen could be improved.
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Affiliation(s)
- Myung S Park
- U S Army Institute of Surgical Research, Fort Sam Houston, Texas, USA.
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Abstract
Therapeutic moderate hypothermia has been advocated for use in traumatic brain injury, stroke, cardiac arrest-induced encephalopathy, neonatal hypoxic-ischemic encephalopathy, hepatic encephalopathy, and spinal cord injury, and as an adjunct to aneurysm surgery. In this review, we address the trials that have been performed for each of these indications, and review the strength of the evidence to support treatment with mild/moderate hypothermia. We review the data to support an optimal target temperature for each indication, as well as the duration of the cooling, and the rate at which cooling is induced and rewarming instituted. Evidence is strongest for prehospital cardiac arrest and neonatal hypoxic-ischemic encephalopathy. For traumatic brain injury, a recent meta-analysis suggests that cooling may increase the likelihood of a good outcome, but does not change mortality rates. For many of the other indications, such as stroke and spinal cord injury, trials are ongoing, but the data are insufficient to recommend routine use of hypothermia at this time.
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Affiliation(s)
- Donald Marion
- The Children's Neurobiological Solutions Foundation, Santa Barbara, California, USA.
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36
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Moor P, Rew D, Midwinter MJ, Doughty H. Transfusion for trauma: civilian lessons from the battlefield? Anaesthesia 2009; 64:469-72. [DOI: 10.1111/j.1365-2044.2008.05829.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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37
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38
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Johansson PI, Bochsen L, Andersen S, Viuff D. Investigation of the effect of kaolin and tissue factor-activated citrated whole blood, on clot forming variables, as evaluated by thromboelastography. Transfusion 2008; 48:2377-83. [DOI: 10.1111/j.1537-2995.2008.01846.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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39
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Nilsson CU, Hellkvist PD, Engström M. Effects of recombinant human activated protein C on the coagulation system: a study with rotational thromboelastometry. Acta Anaesthesiol Scand 2008; 52:1246-9. [PMID: 18823464 DOI: 10.1111/j.1399-6576.2008.01735.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recombinant human activated protein C (rhAPC) is an anticoagulant that can be used for treatment of patients with severe sepsis. The use of rhAPC is accompanied by an increased risk of severe bleeding. Rotational thromboelastometry is a method for measuring the status of the coagulation. The aim of the study was to investigate whether rotational thromboelastometry could be used for monitoring the effects of rhAPC on the coagulation. METHODS Whole blood was mixed in vitro with concentrations of rhAPC ranging from 0 to 75 ng/ml and analysed with rotational thromboelastometry. RESULTS The parameter Coagulation Time was significantly prolonged by increasing the concentrations of rhAPC (P=0.002). Other parameters were not significantly affected. CONCLUSION rhAPC dose dependently affects the early humoral parts of the coagulation, while platelet function and fibrinogen to fibrin conversion seem virtually unaffected.
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Affiliation(s)
- C U Nilsson
- Lund University Medical School, Lund University, Lund, Sweden
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Kirkman E, Watts S, Hodgetts T, Mahoney P, Rawlinson S, Midwinter M. A Proactive Approach to the Coagulopathy of Trauma: The Rationale and Guidelines for Treatment. J ROY ARMY MED CORPS 2007; 153:302-6. [DOI: 10.1136/jramc-153-04-17] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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