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Eralp Inan O, Kocaturk M, Cansev M, Ozarda Y, Yilmaz Z, Ulus IH. Thromboelastographic evaluation of the effectiveness of choline or CDP-choline treatment on endotoxin-induced hemostatic alterations in dogs. Res Vet Sci 2024; 171:105205. [PMID: 38479101 DOI: 10.1016/j.rvsc.2024.105205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/05/2024] [Accepted: 02/28/2024] [Indexed: 04/17/2024]
Abstract
Sepsis/endotoxemia associates with coagulation abnormalities. We showed previously that exogenous choline treatment reversed the changes in platelet count and function as well as prevented disseminated intravascular coagulation (DIC) in endotoxemic dogs. The aim of this follow-up study was to evaluate the effect of treatment with choline or cytidine-5'-diphosphocholine (CDP-choline), a choline donor, on endotoxin-induced hemostatic alterations using thromboelastography (TEG). Dogs were randomized to six groups and received intravenously (iv) saline, choline (20 mg/kg) or CDP-choline (70 mg/kg) in the control groups, whereas endotoxin (0.1 mg/kg, iv) was used alone or in combination with choline or CDP-choline at the same doses in the treatment groups. TEG variables including R- and K-time (clot formation), maximum amplitude (MA) and α-angle (clot stability), G value (clot elasticity), and EPL, A, and LY30 (fibrinolysis), as well as overall assessment of coagulation (coagulation index - CI), were measured before and at 0.5-48 h after the treatments. TEG parameters did not change significantly in the control groups, except for CI parameter after choline administration. Endotoxemia resulted in increased R-time and A value (P < 0.05), decreased K-time (P < 0.05), α-angle (P < 0.001) and CI values (P < 0.01) at different time points. Treatment with either choline or CDP-choline attenuated or prevented completely the alterations in TEG parameters in endotoxemic dogs with CDP-choline being more effective. These results confirm and extend the effectiveness of choline or CDP-choline in endotoxemia by further demonstrating their efficacy in attenuating or preventing the altered viscoelastic properties of blood clot measured by TEG.
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Affiliation(s)
- Oya Eralp Inan
- Department of Animal Science, Eskisehir Osmangazi University Faculty of Agriculture, Eskisehir, Turkey.
| | - Meric Kocaturk
- Department of Internal Medicine, Bursa Uludag University Faculty of Veterinary Medicine, Bursa, Turkey.
| | - Mehmet Cansev
- Department of Pharmacology, Bursa Uludag University Faculty of Medicine, Bursa, Turkey.
| | - Yesim Ozarda
- Department of Biochemistry, Yeditepe University Faculty of Medicine, Istanbul, Turkey.
| | - Zeki Yilmaz
- Department of Internal Medicine, Bursa Uludag University Faculty of Veterinary Medicine, Bursa, Turkey.
| | - Ismail Hakki Ulus
- Department of Pharmacology, Istanbul Okan University Faculty of Medicine, Istanbul, Turkey.
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Cralley AL, Moore EE, LaCroix I, Schaid TJ, Thielen O, Hallas W, Hom P, Mitra S, Kelher M, Hansen K, Cohen M, Silliman C, Sauaia A, Fox CJ. RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA: ZONE 1 REPERFUSION-INDUCED COAGULOPATHY. Shock 2024; 61:322-329. [PMID: 38407818 PMCID: PMC10955717 DOI: 10.1097/shk.0000000000002299] [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] [Indexed: 02/27/2024]
Abstract
ABSTRACT Objective: We sought to identify potential drivers behind resuscitative endovascular balloon occlusion of the aorta (REBOA) induced reperfusion coagulopathy using novel proteomic methods. Background: Coagulopathy associated with REBOA is poorly defined. The REBOA Zone 1 provokes hepatic and intestinal ischemia that may alter coagulation factor production and lead to molecular pathway alterations that compromises hemostasis. We hypothesized that REBOA Zone 1 would lead to reperfusion coagulopathy driven by mediators of fibrinolysis, loss of coagulation factors, and potential endothelial dysfunction. Methods: Yorkshire swine were subjected to a polytrauma injury (blast traumatic brain injury, tissue injury, and hemorrhagic shock). Pigs were randomized to observation only (controls, n = 6) or to 30 min of REBOA Zone 1 (n = 6) or REBOA Zone 3 (n = 4) as part of their resuscitation. Thromboelastography was used to detect coagulopathy. ELISA assays and mass spectrometry proteomics were used to measure plasma protein levels related to coagulation and systemic inflammation. Results: After the polytrauma phase, balloon deflation of REBOA Zone 1 was associated with significant hyperfibrinolysis (TEG results: REBOA Zone 1 35.50% versus control 9.5% vs. Zone 3 2.4%, P < 0.05). In the proteomics and ELISA results, REBOA Zone 1 was associated with significant decreases in coagulation factor XI and coagulation factor II, and significant elevations of active tissue plasminogen activator, plasmin-antiplasmin complex complexes, and syndecan-1 (P < 0.05). Conclusion: REBOA Zone 1 alters circulating mediators of clot formation, clot lysis, and increases plasma levels of known markers of endotheliopathy, leading to a reperfusion-induced coagulopathy compared with REBOA Zone 3 and no REBOA.
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Affiliation(s)
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Aurora, CO USA
- Ernest E Moore Shock Trauma Center at Denver Health Medical Center Surgery, Denver, CO USA
| | - Ian LaCroix
- Department of Proteomics and Metabolomics, University of Colorado, Aurora, CO USA
| | - TJ Schaid
- Department of Surgery, University of Colorado, Aurora, CO USA
| | - Otto Thielen
- Department of Surgery, University of Colorado, Aurora, CO USA
| | - William Hallas
- Department of Surgery, University of Colorado, Aurora, CO USA
| | - Patrick Hom
- Department of Surgery, University of Colorado, Aurora, CO USA
| | | | | | - Kirk Hansen
- Department of Proteomics and Metabolomics, University of Colorado, Aurora, CO USA
| | - Mitchell Cohen
- Department of Surgery, University of Colorado, Aurora, CO USA
| | - Christopher Silliman
- Vitalant Research Institute, Denver, CO USA
- Department of Pediatrics, University of Colorado, Aurora, CO USA
| | - Angela Sauaia
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado Denver, Aurora, CO, USA
| | - Charles J Fox
- Department of Vascular Surgery, University of Maryland Vascular Surgery Baltimore, MD USA
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Lim HJ, Jang H. The first case of hyperfibrinolysis induced by delayed hemolytic transfusion reaction in a trauma patient. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2024; 22:34-36. [PMID: 37146301 PMCID: PMC10812894 DOI: 10.2450/bloodtransfus.507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/02/2023] [Indexed: 05/07/2023]
Affiliation(s)
- Ha Jin Lim
- Department of Laboratory Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Hyunseok Jang
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
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Jakowenko ND, Seelhammer TG, Nabzdyk CGS, Macielak RJ, Nei SD, Kalvelage EL, Wieruszewski PM. Tranexamic Acid for Bleeding Management in Adult Patients on Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:e474-e481. [PMID: 37913503 DOI: 10.1097/mat.0000000000002056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
This study described the outcomes of patients receiving topical, nebulized, endobronchial, or systemic tranexamic acid (TXA) for bleeding events while on extracorporeal membrane oxygenation (ECMO). We performed a single-center case series including adult patients >18 years old supported on either venovenous (VV) or venoarterial (VA) ECMO from January 1, 2014, to April 21, 2021. The primary outcome was hemostatic control defined as a composite of initial cessation of therapeutic interventions to mitigate bleeding or resumption of anticoagulation if previously held. Secondary outcomes included changes in transfusion requirements and lysis at 30-minute (LY30) values, venous thromboembolism (VTE) events, and seizures. In total, 47 patients were included for full analysis. There were 19 patients with surgical bleeds, 18 patients with medical bleeds, and 10 patients with multiple bleeds. Overall, initial hemostatic control was achieved in 79%, 67%, and 90% of patients, respectively. Pre- and post-TXA transfusion requirements were not significantly different ( p = 0.2), although the intraindividual change in median LY30 was -5.1% compared with baseline (95% confidence interval [CI], -12.4% to -1.5%, p = 0.005). The occurrence of VTE and seizures was relatively low and similar among patient bleeding groups. Tranexamic acid provided initial hemostatic control in roughly three quarters of patients with bleeding events on ECMO and side effects were infrequent.
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Affiliation(s)
| | | | | | - Robert J Macielak
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Scott D Nei
- From the Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Errin L Kalvelage
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Patrick M Wieruszewski
- From the Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
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Fuja C, Carll TC, Mikrut K, Wool GD. Sensitivity and specificity of thromboelastography for hyperfibrinolysis: Comparison of TEG 5000 and TEG 6S CK LY30 systems. Am J Clin Pathol 2023; 160:455-465. [PMID: 37415401 DOI: 10.1093/ajcp/aqad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/15/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVES The sensitivity and specificity of clot lysis at 30 minutes after maximum clot strength (LY30), as measured by thromboelastography (TEG), for clinically significant hyperfibrinolysis have not been compared across the 2 US Food and Drug Administration-approved instruments (the TEG 5000 and TEG 6s [Haemonetics]). METHODS We performed a retrospective, single-center analysis of these 2 instruments using the kaolin (CK) reagent. RESULTS Local verification studies showed that the TEG 5000 and TEG 6s CK LY30 upper limits of normal (ULNs) were distinct (5.0% and 3.2%, respectively). Retrospective analysis of patient data showed that abnormal LY30 was 6 times more prevalent with the TEG 6s than with the TEG 5000 instrument. LY30 was a significant predictor of mortality with both instruments (TEG 6s: receiver operating characteristic [ROC] area under the curve [AUC] = 0.836, P ≤ .0001; TEG 5000: ROC AUC = 0.779, P = .028). The optimal LY30 cut point was determined based on these mortality data for each instrument. The TEG 6s showed superior mortality prediction than the TEG 5000 at lower LY30 levels (≥10%), with likelihood ratios of 8.22 and 2.62 for the TEG 6s and TEG 5000, respectively. Patients with a TEG 6s CK LY30 of 10% or higher were significantly more likely to die, receive cryoprecipitate, receive transfusions, or receive massive transfusion than patients with a TEG 6s LY30 of 3.3% to 9.9% (all P < .01). Patients with a TEG 5000 LY30 of 17.1% or higher were significantly more likely to die or use cryoprecipitate (P < .05); transfusion and massive transfusion protocol were not significantly different. Whole blood spiking studies showed that 70 ng/mL tissue plasminogen activator (tPA) achieved an average LY30 of approximately 10% for both instruments. CONCLUSIONS CK LY30 above the ULN is a sensitive but not specific cutoff for hyperfibrinolysis. At least moderately elevated CK LY30 carries more clinical portent on the TEG 6s instrument than on the TEG 5000. These TEG instruments are not sensitive to low concentrations of tPA.
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Affiliation(s)
- Christine Fuja
- Department of Pathology, University of Chicago, Chicago, IL, US
| | - Timothy C Carll
- Department of Pathology, University of Chicago, Chicago, IL, US
| | - Krzysztof Mikrut
- Clinical Laboratories, University of Chicago Medicine, Chicago, IL, US
| | - Geoffrey D Wool
- Department of Pathology, University of Chicago, Chicago, IL, US
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Rosebery L, Miller M, Loizou P, Ho SJ, Adkins KJ, Deshpande K. A retrospective validation of ROTEM algorithms for detecting hyperfibrinolysis demonstrates poor agreement for prediction of in-hospital mortality and transfusion requirement in a general, non-cardiac, surgical population. Thromb Res 2023; 229:170-177. [PMID: 37517207 DOI: 10.1016/j.thromres.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/02/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION Hyperfibrinolysis diagnosed on Rotational Thromboelastography (ROTEM) is associated with increased transfusion requirements and mortality in trauma. The diagnosis and significance of hyperfibrinolysis in a mixed, non-cardiac, general surgical population has not been investigated. We aimed to measure agreement between four ROTEM algorithms for diagnosing hyperfibrinolysis and transfusion requirements and mortality in general surgical patients. These algorithms mostly incorporate measures of early or late clot amplitude reduction on the Extrinsic Clotting Pathway Test with Tissue Factor (EXTEM) channel. METHOD Four hospital administrative data sets were linked from 2019 to 2022. Adults >18 years were included if a ROTEM was performed during their surgery (intraoperative period) or within 24-h of the surgery completion (postoperative period). The four hyperfibrinolysis criteria were applied to the ROTEM data and assessed for their agreement, intraoperative and postoperative transfusion requirements and in-patient mortality. RESULTS We linked 933 ROTEMs to 558 patient-procedures. One algorithm identified hyperfibrinolysis on only three patients so was excluded. Agreement between the remaining three was slight (Cohens Kappa 0.18 (p < 0.001)) with hyperfibrinolysis diagnosed between 22 and 69 % of the procedures. The association between hyperfibrinolysis diagnosis and intraoperative or postoperative transfusion requirement was inconsistent between the criteria. However, an algorithm put forward by Goerling et al. was more often associated with transfusion requirement and inpatient mortality. DISCUSSION The poor agreement between criteria suggests that some ROTEM criteria may not transfer directly to general surgical patients. Future research should focus on optimising hyperfibrinolysis cut-off values to update algorithms for bleeding general surgical patients.
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Affiliation(s)
- Leon Rosebery
- Intensive Care Unit, St George Hospital, Gray St, Kogarah 2217, Australia
| | - Matthew Miller
- Department of Anaesthesia, St George Hospital, Gray St, Kogarah 2217, Australia; Conjoint Lecturer St George and Sutherland Clinical Campus, UNSW, Sydney, Australia.
| | - Peter Loizou
- Blood Bank Department, StG Public Hospital, Kogarah, NSW 2217, Australia
| | - Shir Jing Ho
- Conjoint Lecturer St George and Sutherland Clinical Campus, UNSW, Sydney, Australia; Department of Haematology, St George Hospital, Kogarah, NSW 2217, Australia
| | - Keith J Adkins
- Department of Perfusion, St George Hospital, Gray St, Kogarah, NSW 2217, Australia
| | - Kush Deshpande
- Intensive Care Unit, St George Hospital, Gray St, Kogarah 2217, Australia; Conjoint Lecturer St George and Sutherland Clinical Campus, UNSW, Sydney, Australia
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Russo RM, Lozano R, Ruf AC, Ho JW, Strayve D, Zakaluzny SA, Keeney-Bonthrone TP. A Systematic Review of Tranexamic Acid-Associated Venous Thromboembolic Events in Combat Casualties and Considerations for Prolonged Field Care. Mil Med 2023; 188:e2932-e2940. [PMID: 36315470 DOI: 10.1093/milmed/usac317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/13/2022] [Accepted: 10/03/2022] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) is a standard component of Tactical Combat Casualty Care. Recent retrospective studies have shown that TXA use is associated with a higher rate of venous thromboembolic (VTE) events in combat-injured patients. We aim to determine if selective administration should be considered in the prolonged field care environment. MATERIALS AND METHODS We performed a systematic review using the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Clinical trials and observational studies of combat casualties published between January 1, 1960, and June 20, 2022, were included. We analyzed survival and VTE outcomes in TXA recipients and non-recipients. We discussed the findings of each paper in the context of current and future combat environments. RESULTS Six articles met criteria for inclusion. Only one study was powered to report mortality data, and it demonstrated a 7-fold increase in survival in severely injured TXA recipients. All studies reported an increased risk of VTE in TXA recipients, which exceeded rates in civilian literature. However, five of the six studies used overlapping data from the same registry and were limited by a high rate of missingness in pertinent variables. No VTE-related deaths were identified. CONCLUSIONS There may be an increased risk of VTE in combat casualties that receive TXA; however, this risk must be considered in the context of improved survival and an absence of VTE-associated deaths. To optimize combat casualty care during prolonged field care, it will be essential to ensure the timely administration of VTE chemoprophylaxis as soon as the risk of significant hemorrhage permits.
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Affiliation(s)
- Rachel M Russo
- Department of Surgery, University of California, Sacramento, CA 95817, USA
- Department of Surgery, David Grant USAF Medical Center, Fairfield, CA 94535, USA
| | - Rafael Lozano
- Department of Surgery, University of California, Sacramento, CA 95817, USA
- Department of Surgery, David Grant USAF Medical Center, Fairfield, CA 94535, USA
| | - Ashly C Ruf
- Department of Surgery, University of California, Sacramento, CA 95817, USA
- Department of Surgery, David Grant USAF Medical Center, Fairfield, CA 94535, USA
| | - Jessie W Ho
- Department of Surgery, Northwestern University, Evanston, IL 60611, USA
| | - Daniel Strayve
- Department of Surgery, University of California, Sacramento, CA 95817, USA
- Department of Surgery, David Grant USAF Medical Center, Fairfield, CA 94535, USA
| | - Scott A Zakaluzny
- Department of Surgery, University of California, Sacramento, CA 95817, USA
- Department of Surgery, David Grant USAF Medical Center, Fairfield, CA 94535, USA
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LaCroix IS, Cohen M, Moore EE, Dzieciatkowska M, Silliman CC, Hansen KC, D'Alessandro A. Omics markers of platelet transfusion in trauma patients. Transfusion 2023; 63:1447-1462. [PMID: 37466356 DOI: 10.1111/trf.17472] [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: 02/21/2023] [Revised: 04/26/2023] [Accepted: 05/30/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Even in the era of the COVID-19 pandemic, trauma remains the global leading cause of mortality under the age of 49. Trauma-induced coagulopathy is a leading driver of early mortality in critically ill patients, and transfusion of platelet products is a life-saving intervention to restore hemostasis in the bleeding patient. However, despite extensive functional studies based on viscoelastic assays, limited information is available about the impact of platelet transfusion on the circulating molecular signatures in trauma patients receiving platelet transfusion. MATERIALS AND METHODS To bridge this gap, we leveraged metabolomics and proteomics approaches to characterize longitudinal plasma samples (n = 118; up to 11 time points; total samples: 759) from trauma patients enrolled in the Control Of Major Bleeding After Trauma (COMBAT) study. Samples were collected in the field, in the emergency department (ED), and at intervals up to 168 h (7 days) post-hospitalization. Transfusion of platelet (PLT) products was performed (n = 30; total samples: 250) in the ED through 24 h post-hospitalization. Longitudinal plasma samples were subjected to mass spectrometry-based metabolomics and proteomics workflows. Multivariate analyses were performed to determine omics markers of transfusion of one, two, three, or more PLT transfusions. RESULTS Higher levels of tranexamic acid (TXA), inflammatory proteins, carnitines, and polyamines were detected in patients requiring PLT transfusion. Correlation of PLT units with omics data suggested sicker patients required more units and partially overlap with the population requiring transfusion of packed red blood cell products. Furthermore, platelet activation was likely increased in the most severely injured patients. Fatty acid levels were significantly lower in PLT transfusion recipients (at time of maximal transfusion: Hour 4) compared with non-recipients, while carnitine levels were significantly higher. Fatty acid levels restore later in the time course (e.g., post-PLT transfusion). DISCUSSION The present study provides the first multi-omics characterization of platelet transfusion efficacy in a clinically relevant cohort of trauma patients. Physiological alterations following transfusion were detected, highlighting the efficacy of mass spectrometry-based omics techniques to improve personalized transfusion medicine. More specialized clinical research studies focused on PLT transfusion, including organized pre and post transfusion sample collection and limitation to PLT products only, are required to fully understand subsequent metabolomic and proteomic alterations.
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Affiliation(s)
- Ian S LaCroix
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mitchell Cohen
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ernest E Moore
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
- "Ernest E Moore" Trauma Center at Denver Health, Denver, Colorado, USA
| | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher C Silliman
- Vitalant Research Institute, Denver, Colorado, USA
- Department of Pediatrics, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
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Cralley AL, Moore EE, Coleman JR, Vigneshwar N, Bartley M, Kissau D, Eitel A, Hom P, Mitra S, Ghasabyan A, Fragoso M, Guo Z, Deguchi H, Griffin JH, Cohen MJ, Silliman CC, Banerjee A, Hansen K, Sauaia A. Hemorrhagic shock and tissue injury provoke distinct components of trauma-induced coagulopathy in a swine model. Eur J Trauma Emerg Surg 2023; 49:1079-1089. [PMID: 36319860 PMCID: PMC10802987 DOI: 10.1007/s00068-022-02148-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/14/2022] [Indexed: 03/02/2023]
Abstract
INTRODUCTION Tissue injury (TI) and hemorrhagic shock (HS) are the major contributors to trauma-induced coagulopathy (TIC). However, the individual contributions of these insults are difficult to discern clinically because they typically coexist. TI has been reported to release procoagulants, while HS has been associated with bleeding. We developed a large animal model to isolate TI and HS and characterize their individual mechanistic pathways. We hypothesized that while TI and HS are both drivers of TIC, they provoke different pathways; specifically, TI reduces time to clotting, whereas, HS decreases clot strength stimulates hyperfibrinolysis. METHODS After induction of general anesthesia, 50 kg male, Yorkshire swine underwent isolated TI (bilateral muscle cutdown of quadriceps, bilateral femur fractures) or isolated HS (controlled bleeding to a base excess target of - 5 mmol/l) and observed for 240 min. Thrombelastography (TEG), calcium levels, thrombin activatable fibrinolysis inhibitor (TAFI), protein C, plasminogen activator inhibitor 1 (PAI-1), and plasminogen activator inhibitor 1/tissue-type plasminogen activator complex (PAI-1-tPA) were analyzed at pre-selected timepoints. Linear mixed models for repeated measures were used to compare results throughout the model. RESULTS TI resulted in elevated histone release which peaked at 120 min (p = 0.02), and this was associated with reduced time to clot formation (R time) by 240 min (p = 0.006). HS decreased clot strength at time 30 min (p = 0.003), with a significant decline in calcium (p = 0.001). At study completion, HS animals had elevated PAI-1 (p = 0.01) and PAI-1-tPA (p = 0.04), showing a trend toward hyperfibrinolysis, while TI animals had suppressed fibrinolysis. Protein C, TAFI and skeletal myosin were not different among the groups. CONCLUSION Isolated injury in animal models can help elucidate the mechanistic pathways leading to TIC. Our results suggest that isolated TI leads to early histone release and a hypercoagulable state, with suppressed fibrinolysis. In contrast, HS promotes poor clot strength and hyperfibrinolysis resulting in hypocoagulability.
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Affiliation(s)
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Aurora, CO, USA
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Julia R Coleman
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | | | - Matt Bartley
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Daniel Kissau
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Andrew Eitel
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Patrick Hom
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | | | - Arsen Ghasabyan
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Miguel Fragoso
- Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Zihan Guo
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - Hiroshi Deguchi
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - John H Griffin
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
- Department of Medicine, University of California, San Diego, CA, USA
| | | | - Christopher C Silliman
- Vitalant Research Institute, Denver, CO, USA
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
| | | | - Kirk Hansen
- Department of Proteomics and Metabolomics, University of Colorado, Aurora, CO, USA
| | - Angela Sauaia
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado Denver, Aurora, CO, USA
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Volod O, Runge A. Measurement of Blood Viscoelasticity Using Thromboelastography. Methods Mol Biol 2023; 2663:709-724. [PMID: 37204747 DOI: 10.1007/978-1-0716-3175-1_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Thromboelastography (TEG) was the first viscoelastic test (VET), invented in Germany in 1948 by Dr. Hartert, and which evaluates the hemostatic competence of whole blood. Thromboelastography was introduced before the activated partial thromboplastin time (aPTT), which was devised in 1953. TEG was not widely used until the introduction of a cell-based model of hemostasis (1994) showing the importance of platelets and tissue factor in hemostasis. Nowadays, VET has become an essential method for assessing hemostatic competence in cardiac surgery, liver transplantation, and trauma. TEG has undergone several modifications, but the concept on which the original TEG was based (cup and pin technology) remained in up to the TEG 5000 analyzer (Haemonetics, Braintree, MA). A new generation of thromboelastography, TEG 6s (Haemonetics, Boston, MA), that assesses blood viscoelastic properties by resonance technology has recently been developed. This newer methodology represents a cartridge-based, automated assay aimed to improve on historical TEG performance and precision. In the present chapter, we will review the advantages and limitations of TEG 5000 and TEG 6s systems as well as factors that affect TEG and which must be considered when interpreting TEG tracings.
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Affiliation(s)
- Oksana Volod
- Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Alice Runge
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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11
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Jones WL, Ramos CR, Banerjee A, Moore EE, Hansen KC, Coleman JR, Kelher M, Neeves KB, Silliman CC, Di Paola J, Branchford BR. Apolipoprotein A-I, elevated in trauma patients, inhibits platelet activation and decreases clot strength. Platelets 2022; 33:1119-1131. [PMID: 35659185 PMCID: PMC9547822 DOI: 10.1080/09537104.2022.2078488] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 04/19/2022] [Accepted: 04/29/2022] [Indexed: 10/18/2022]
Abstract
Apolipoprotein A-I (ApoA-I) is elevated in the plasma of a subgroup of trauma patients with systemic hyperfibrinolysis. We hypothesize that apoA-I inhibits platelet activation and clot formation. The effects of apoA-I on human platelet activation and clot formation were assessed by whole blood thrombelastography (TEG), platelet aggregometry, P-selectin surface expression, microfluidic adhesion, and Akt phosphorylation. Mouse models of carotid artery thrombosis and pulmonary embolism were used to assess the effects of apoA-I in vivo. The ApoA-1 receptor was investigated with transgenic mice knockouts (KO) for the scavenger receptor class B member 1 (SR-BI). Compared to controls, exogenous human apoA-I inhibited arachidonic acid and collagen-mediated human and mouse platelet aggregation, decreased P-selectin surface expression and Akt activation, resulting in diminished clot strength and increased clot lysis by TEG. ApoA-I also decreased platelet aggregate size formed on a collagen surface under flow. In vivo, apoA-I delayed vessel occlusion in an arterial thrombosis model and conferred a survival advantage in a pulmonary embolism model. SR-BI KO mice significantly reduced apoA-I inhibition of platelet aggregation versus wild-type platelets. Exogenous human apoA-I inhibits platelet activation, decreases clot strength and stability, and protects mice from arterial and venous thrombosis via the SR-BI receptor.
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Affiliation(s)
- Wilbert L Jones
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Christopher R. Ramos
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Anirban Banerjee
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Ernest E. Moore
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
- Dept. of Surgery, Denver Health Medical Center, Denver CO
| | - Kirk C. Hansen
- Department of Biochemistry/Molecular Genetics, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Julia R. Coleman
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Marguerite Kelher
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
- Vitalant Research Institute, Denver, CO
| | - Keith B. Neeves
- Department of Pediatrics, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
- Department of Bioengineering, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
| | - Christopher C. Silliman
- Department of Surgery, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
- Department of Pediatrics, School of Medicine University of Colorado Denver, Anschutz Medical Campus, Aurora, CO
- Vitalant Research Institute, Denver, CO
| | - Jorge Di Paola
- Dept. of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, MO
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12
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Lawson MA, Holle LA, Dow NE, Hennig G, de Laat B, Moore HB, Moore EE, Cohen MJ, Bouchard BA, Freeman K, Wolberg AS. Plasma-based assays distinguish hyperfibrinolysis and shutdown subgroups in trauma-induced coagulopathy. J Trauma Acute Care Surg 2022; 93:579-587. [PMID: 35687811 PMCID: PMC9613511 DOI: 10.1097/ta.0000000000003723] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma patients with abnormal fibrinolysis have increased morbidity and mortality. Knowledge of mechanisms differentiating fibrinolytic phenotypes is important to optimize treatment. We hypothesized that subjects with abnormal fibrinolysis identified by whole blood viscoelastometry can also be distinguished by plasma thrombin generation, clot structure, fibrin formation, and plasmin generation measurements. METHODS Platelet-poor plasma (PPP) from an observational cross-sectional trauma cohort with fibrinolysis shutdown (% lysis at 30 minutes [LY30] < 0.9, n = 11) or hyperfibrinolysis (LY30 > 3%, n = 9) defined by whole blood thromboelastography were studied. Noninjured control subjects provided comparative samples. Thrombin generation, fibrin structure and formation, and plasmin generation were measured by fluorescence, confocal microscopy, turbidity, and a fluorescence-calibrated plasmin assay, respectively, in the absence/presence of tissue factor or tissue plasminogen activator (tPA). RESULTS Whereas spontaneous thrombin generation was not detected in PPP from control subjects, PPP from hyperfibrinolysis or shutdown patients demonstrated spontaneous thrombin generation, and the lag time was shorter in hyperfibrinolysis versus shutdown. Addition of tissue factor masked this difference but revealed increased thrombin generation in hyperfibrinolysis samples. Compared with shutdown, hyperfibrinolysis PPP formed denser fibrin networks. In the absence of tPA, the fibrin formation rate was faster in shutdown than hyperfibrinolysis, but hyperfibrinolysis clots lysed spontaneously; these differences were masked by addition of tPA. Tissue plasminogen activator-stimulated plasmin generation was similar in hyperfibrinolysis and shutdown samples. Differences in LY30, fibrin structure, and lysis correlated with pH. CONCLUSION This exploratory study using PPP-based assays identified differences in thrombin generation, fibrin formation and structure, and lysis in hyperfibrinolysis and shutdown subgroups. These groups did not differ in their ability to promote tPA-triggered plasmin generation. The ability to characterize these activities in PPP facilitates studies to identify mechanisms that promote adverse outcomes in trauma. LEVEL OF EVIDENCE Prognostic/Epidemiological; Level III.
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Affiliation(s)
| | - Lori A. Holle
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nathan E. Dow
- Department of Surgery, University of Vermont, Burlington, VT, USA
| | - Grant Hennig
- Department of Pharmacology, University of Vermont, Burlington, VT, USA
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands
| | - Hunter B. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ernest E. Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Mitchell J. Cohen
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Beth A. Bouchard
- Department of Biochemistry and Laboratory for Clinical Biochemistry Research, University of Vermont, Burlington, VT, USA
| | - Kalev Freeman
- Department of Surgery, University of Vermont, Burlington, VT, USA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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13
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Yang S, McRae HL, Terry T, Cahill CM, Refaai MA. Evaluation of a Newly Implemented Critical Thromboelastography (TEG) Value Callback System. Am J Clin Pathol 2022; 158:667-671. [PMID: 36250747 DOI: 10.1093/ajcp/aqac114] [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: 05/11/2022] [Accepted: 08/18/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Thromboelastography (TEG) measures whole blood coagulation kinetics in real time and is useful in guiding blood product transfusion. At our institution, providers have immediate remote access to TEG results. However, some critical values are occasionally missed. Our patient blood management program implemented a critical TEG value callback system to improve patient management and blood product utilization. METHODS This retrospective, observational study assessed the data of trauma and critical care patients preimplementation (n = 20) and postimplementation (n = 100) of the callback system. Provider responses to callbacks and changes in TEG parameters after subsequent testing were compared between the two groups. RESULTS In response to callbacks, 42% provided appropriate management and 42% ordered a repeat TEG vs 28% and 33% in the historical group (P < .0001 and P = .0002, respectively). Following callback, 90% of the TEG parameters in the study group showed an improvement vs 57% in the control group (P = .011). CONCLUSIONS The increase in appropriate management and the improvement in TEG parameters upon repeat testing in the study group compared to the control group demonstrate the efficacy of the TEG callback system. Further studies are needed to evaluate the callback system effect on patient outcome.
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Affiliation(s)
- Shanna Yang
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, Hemostasis and Thrombosis Unit, University of Rochester Medical Center, Rochester, NY, USA
| | - Hannah L McRae
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, Hemostasis and Thrombosis Unit, University of Rochester Medical Center, Rochester, NY, USA
| | - Treyc Terry
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, Hemostasis and Thrombosis Unit, University of Rochester Medical Center, Rochester, NY, USA
| | - Christine M Cahill
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, Hemostasis and Thrombosis Unit, University of Rochester Medical Center, Rochester, NY, USA
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, Hemostasis and Thrombosis Unit, University of Rochester Medical Center, Rochester, NY, USA
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14
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Zoia A, Drigo M, Caldin M, Simioni P, Piek CJ. Fibrinolysis in Dogs with Intracavitary Effusion: A Review. Animals (Basel) 2022; 12:ani12192487. [PMID: 36230236 PMCID: PMC9558497 DOI: 10.3390/ani12192487] [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: 06/09/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 11/23/2022] Open
Abstract
Simple Summary In blood vessels there is a balance between clot formation and its dissolution. Fibrinolysis normally allows the breakdown of blood clots during the healing of injured blood vessels. This process is mediated by the activation of a blood enzyme (plasmin) which breaks down a meshed protein (fibrin) which holds blood clots at the site of the vessel injury. In some diseases, the activation of plasmin becomes excessive, leading to bleeding tendencies (hyperfibrinolysis). Under normal conditions, abdominal and thoracic cavities are filled with a small amount of fluid deriving from the blood. The results of recent studies have shown that, in dogs, all types of pathologic intracavitary fluids have an increased fibrinolytic activity. This increased fibrinolytic activity is also present in their blood, in some cases reaching a hyperfibrinolytic state. Hyperfibrinolysis and bleeding tendencies have also been documented in cardiopathic dogs with ascites. The latter result is surprising considering that thrombotic events are commonly documented in humans and cats with some cardiac diseases. Abstract Physiologic fibrinolysis is a localized process in which stable fibrin strands are broken down by plasmin in response to thrombosis. Plasmin activation can also take place separately from the coagulation process, resulting in pathologic fibrinolysis. When plasmin activation exceeds the neutralizing capacity of plasmin inhibitors, severe bleeding can potentially take place. Although the processes which regulate coagulation and fibrinolysis in the blood are well known, it is less clear as to what extent the same processes take place in the body cavities and whether they influence systemic hemostasis. The results of the studies herein cited demonstrate that coagulation followed by fibrinogenolytic/fibrinolytic activity takes place in all kinds of canine ascitic and pleural fluids. Moreover, systemic clotting abnormalities suggesting primary fibrinolysis/primary hyperfibrinolysis (i.e., elevated plasma fibrin/fibrinogen degradation products [FDPs] and normal D-dimer concentrations with fibrinogen concentrations ≤ 100 mg/dL or above this cut-off, respectively) occur in dogs with intracavitary effusion. Enhanced fibrinolytic activity in dogs with intracavitary effusion can also be detected using rotational thromboelastometry (ROTEM), although the degree of agreement between ROTEM and FDPs, D-dimer and fibrinogen concentrations is poor. Finally, contrary to the thrombotic events commonly documented in some humans and cats with cardiac diseases, bleeding tendencies due to primary fibrinolysis/primary hyperfibrinolysis have been documented in dogs with cardiogenic ascites.
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Affiliation(s)
- Andrea Zoia
- Division of Internal Medicine, San Marco Veterinary Clinic, Viale dell’Industria 3, 35030 Veggiano, Italy
- Correspondence: ; Tel.: +39-049-8561098
| | - Michele Drigo
- Department of Medicina Animale, Produzione e Salute, Padua University, Viale dell’Università 16, 35020 Legnaro, Italy
| | - Marco Caldin
- Laboratorio d’Analisi Veterinarie San Marco, Viale dell’Industria 3, Veggiano, 35030 Padua, Italy
| | - Paolo Simioni
- Department of Cardiologic, Thoracic and Vascular Sciences, University of Padua Medical School, Via Giustiniani 2, 35128 Padua, Italy
| | - Christine J. Piek
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, 8 Heidelberglaan, 3584 CS Utrecht, The Netherlands
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15
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Pourang S, Sekhon UDS, Disharoon D, Ahuja SP, Suster MA, Sen Gupta A, Mohseni P. Assessment of fibrinolytic status in whole blood using a dielectric coagulometry microsensor. Biosens Bioelectron 2022; 210:114299. [PMID: 35533507 PMCID: PMC10124761 DOI: 10.1016/j.bios.2022.114299] [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] [Received: 02/20/2022] [Revised: 04/12/2022] [Accepted: 04/19/2022] [Indexed: 02/09/2023]
Abstract
Rapid assessment of the fibrinolytic status in whole blood at the point-of-care/point-of-injury (POC/POI) is clinically important to guide timely management of uncontrolled bleeding in patients suffering from hyperfibrinolysis after a traumatic injury. In this work, we present a three-dimensional, parallel-plate, capacitive sensor - termed ClotChip - that measures the temporal variation in the real part of blood dielectric permittivity at 1 MHz as the sample undergoes coagulation within a microfluidic channel with <10 μL of total volume. The ClotChip sensor features two distinct readout parameters, namely, lysis time (LT) and maximum lysis rate (MLR) that are shown to be sensitive to the fibrinolytic status in whole blood. Specifically, LT identifies the time that it takes from the onset of coagulation for the fibrin clot to mostly dissolve in the blood sample during fibrinolysis, whereas MLR captures the rate of fibrin clot lysis. Our findings are validated through correlative measurements with a rotational thromboelastometry (ROTEM) assay of clot viscoelasticity, qualitative/quantitative assessments of clot stability, and scanning electron microscope imaging of clot ultrastructural changes, all in a tissue plasminogen activator (tPA)-induced fibrinolytic environment. Moreover, we demonstrate the ClotChip sensor ability to detect the hemostatic rescue that occurs when the tPA-induced upregulated fibrinolysis is inhibited by addition of tranexamic acid (TXA) - a potent antifibrinolytic drug. This work demonstrates the potential of ClotChip as a diagnostic platform for rapid POC/POI assessment of fibrinolysis-related hemostatic abnormalities in whole blood to guide therapy.
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Affiliation(s)
- Sina Pourang
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Ujjal D S Sekhon
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Dante Disharoon
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Sanjay P Ahuja
- Division of Pediatric Hematology/Oncology, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Michael A Suster
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Anirban Sen Gupta
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA.
| | - Pedram Mohseni
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA; Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA.
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16
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Moore HB, Neal MD, Bertolet M, Joughin BA, Yaffe MB, Barrett CD, Bird MA, Tracy RP, Moore EE, Sperry JL, Zuckerbraun BS, Park MS, Cohen MJ, Wisniewski SR, Morrissey JH. Proteomics of Coagulopathy Following Injury Reveals Limitations of Using Laboratory Assessment to Define Trauma-Induced Coagulopathy to Predict Massive Transfusion. ANNALS OF SURGERY OPEN 2022; 3:e167. [PMID: 36177090 PMCID: PMC9514137 DOI: 10.1097/as9.0000000000000167] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 04/18/2022] [Indexed: 10/18/2022] Open
Abstract
Objective Trauma-induced coagulopathy (TIC) is provoked by multiple mechanisms and is perceived to be one driver of massive transfusions (MT). Single laboratory values using prothrombin time (INR) or thrombelastography (TEG) are used to clinically define this complex process. We used a proteomics approach to test whether current definitions of TIC (INR, TEG, or clinical judgement) are sufficient to capture the majority of protein changes associated with MT. Methods Eight level-I trauma centers contributed blood samples from patients available early after injury. TIC was defined as INR >1.5 (INR-TIC), TEG maximum amplitude <50mm (TEG-TIC), or clinical judgement (Clin-TIC) by the trauma surgeon. MT was defined as > 10 units of red blood cells in 24 hours or > 4 units RBC/hour during the first 4 hr. SomaLogic proteomic analysis of 1,305 proteins was performed. Pathways associated with proteins dysregulated in patients with each TIC definition and MT were identified. Results Patients (n=211) had a mean injury severity score of 24, with a MT and mortality rate of 22% and 12%, respectively. We identified 578 SOMAscan analytes dysregulated among MT patients, of which INR-TIC, TEG-TIC, and Clin-TIC patients showed dysregulation only in 25%, 3%, and 4% of these, respectively. TIC definitions jointly failed to show changes in 73% of the protein levels associated with MT, and failed to identify 26% of patients that received a massive transfusion. INR-TIC and TEG-TIC patients showed dysregulation of proteins significantly associated with complement activity. Proteins dysregulated in Clin-TIC or massive transfusion patients were not significantly associated with any pathway. Conclusion These data indicate there are unexplored opportunities to identify patients at risk for massive bleeding. Only a small subset of proteins that are dysregulated in patients receiving MT are statistically significantly dysregulated among patients whose TIC is defined based solely on laboratory measurements or clinical assessment.
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Affiliation(s)
- Hunter B. Moore
- From the Department of Surgery, University of Colorado, Denver, CO
| | - Matthew D. Neal
- Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Marnie Bertolet
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Brian A. Joughin
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA
- Center for Precision Cancer Medicine
| | - Michael B. Yaffe
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA
- Center for Precision Cancer Medicine
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Cambridge, MA
| | - Christopher D. Barrett
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Cambridge, MA
| | - Molly A. Bird
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
- Koch Institute for Integrative Cancer Research at MIT, Cambridge, MA
- Center for Precision Cancer Medicine
| | - Russell P. Tracy
- University of Vermont, Department of Biochemistry, Burlington, VT
| | - Ernest E Moore
- From the Department of Surgery, University of Colorado, Denver, CO
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO
| | - Jason L. Sperry
- Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Brian S. Zuckerbraun
- Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Myung S. Park
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN
| | | | | | - James H. Morrissey
- Departments of Biological Chemistry and Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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17
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Vigneshwar NG, Moore EE, Moore HB, Cotton BA, Holcomb JB, Cohen MJ, Sauaia A. Precision Medicine: Clinical Tolerance to Hyperfibrinolysis Differs by Shock and Injury Severity. Ann Surg 2022; 275:e605-e607. [PMID: 33214445 PMCID: PMC8589450 DOI: 10.1097/sla.0000000000004548] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The definition of hyperfibrinolysis based on thrombelastogram LY30 measurements should vary with trauma patient characteristics, i.e., as anatomic injury or shock severity increase, the ability to tolerate even mild degrees of fibrinolysis is markedly reduced. This trend is independent of institutional practice patterns. The management of hyperfibrinolysis, particularly with anti-fibrinolytics administration, should be interpreted in the context of injury severity/shock and managed on an individual patient basis.
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Affiliation(s)
- Navin G Vigneshwar
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Hunter B Moore
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Bryan A Cotton
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - John B Holcomb
- Department of Surgery, The McGovern Medical School at the University of Texas Health Science Center, Houston, Texas
| | - Mitchell J Cohen
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Angela Sauaia
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- Department of Health Systems, Management and Policy, University of Colorado School of Public Health, Aurora, Colorado
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18
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George S, Wake E, Sweeny A, Campbell D, Winearls J. Rotational thromboelastometry in children presenting to an Australian major trauma centre: A retrospective cohort study. Emerg Med Australas 2022; 34:590-598. [PMID: 35203106 PMCID: PMC9542394 DOI: 10.1111/1742-6723.13939] [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] [Received: 09/06/2021] [Revised: 01/09/2022] [Accepted: 01/29/2022] [Indexed: 12/22/2022]
Abstract
Objective This retrospective cohort study aims to describe patterns of rotational thromboelastometry (ROTEM™) results in paediatric trauma following the implementation of a ROTEM‐guided critical bleeding algorithm and major haemorrhage protocol (MHP). Methods This retrospective observational study was conducted in a tertiary trauma hospital in Queensland, Australia, where point‐of‐care ROTEM was introduced for paediatric patients in 2014. All children aged less than 18 years who had a ROTEM test during their presentation between January 2014 and December 2017 for a traumatic injury were included in the dataset. Other children with a record in the hospital's trauma registry in the same period were also screened for blood product usage. Data were collected for frequency of ROTEM testing, pathology and ROTEM results, blood product and antifibrinolytic use along with injury related data. Compliance with recommended treatment thresholds for detected coagulopathy was also reviewed. Results A total of 1039 children were listed in the trauma registry, including 167 children having a ROTEM test for trauma. Factors significantly associated with having a ROTEM test were older age, higher injury severity score (ISS >12) and penetrating injury. A result exceeding a treatment threshold was returned for 122 (73.1%) of 167 children, with hyperfibrinolysis identified in 88 (52.6%) of 167 and hypofibrinogenaemia identified in 54 (32.3%) of 167. Adherence with the recommended treatments for those children where a treatment threshold was exceeded was low in this cohort. Conclusion The use of ROTEM‐guided blood component replacement is an emerging practice in children for both traumatic and non‐traumatic bleeding. Targeted replacement of identified coagulation defects guided by rapid point‐of‐care testing is an emerging alternative to fixed‐ratio‐based protocols. Further research is required to validate treatment thresholds in the paediatric population and further investigate the clinical outcomes for patients as a result of early correction of trauma‐induced coagulopathy.
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Affiliation(s)
- Shane George
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Elizabeth Wake
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Trauma Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Amy Sweeny
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Faculty of Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Don Campbell
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Trauma Service, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - James Winearls
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,Intensive Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Brisbane, Queensland, Australia
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19
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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: 35] [Impact Index Per Article: 17.5] [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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20
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Thromboelastography is predictive of mortality, blood transfusions, and blood loss in patients with traumatic pelvic fractures: a retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:345-350. [PMID: 33175987 PMCID: PMC8371986 DOI: 10.1007/s00068-020-01533-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 10/17/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE In patients with traumatic pelvic fractures, thromboelastography (TEG) is a useful tool to rapidly evaluate and identify coagulation disturbances. The purpose of this study was to examine the coagulation kinetics of patients with traumatic pelvic fractures (pelvic ring and/or acetabulum) by analyzing the TEG results at initial presentation and its relationship with mortality and blood loss. METHODS A retrospective review at our Level-1 trauma center was conducted to identify Full Trauma Team activations (FTTa) with traumatic pelvic and/or acetabular fractures who were evaluated with a TEG on initial presentation between 2012 and 2016. In-hospital mortality, product transfusion, and hemoglobin changes were analyzed. Subgroup analysis was performed based on pelvic fracture type. RESULTS 141 patients with a mean age of 49.0 ± 20.8 years and mean Injury Severity Score (ISS) of 25.18 ± 12.8 met inclusion criteria. PRBC transfusion occurred in 78.0% of patients; a total of 1486 blood products were transfused. A total of 65 patients (46.1%) underwent operative treatment for the pelvic injuries, and 18 patients (12.7%) required embolization. The overall in-hospital mortality rate was 14.9%. The degree of clot lysis at 30 min (LY30) was significantly associated with blood loss (p < 0.0001), units of packed red blood cells (PRBCs) transfused (p < 0.0001), and mortality rate (p = 0.0002). CONCLUSION Increased fibrinolysis evidenced by an elevated LY30 on initial TEG in patients with traumatic pelvic fractures is associated with increased blood loss, blood product transfusions, and mortality. Future studies should evaluate the clinical utility of reversing hyperfibrinolysis on initial TEG. LEVEL OF EVIDENCE Prognostic level III.
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Thota B, Marinica A, Oh MW, Cripps MW, Moon TS. The Use of Tranexamic Acid in Trauma. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00509-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Lu CH, Zheng ZH, Yeh TT, Yeh CC. Practice algorithm of rotational thromboelastometry-guided bleeding management in trauma and orthopedic surgery. JOURNAL OF MEDICAL SCIENCES 2022. [DOI: 10.4103/jmedsci.jmedsci_122_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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23
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Morton AP, Hadley JB, Ghasabyan A, Kelher MR, Moore EE, Bevers S, Dzieciatkowska M, Hansen KC, Cohen MS, Banerjee A, Silliman CC. The α-globin chain of hemoglobin potentiates tissue plasminogen activator induced hyperfibrinolysis in vitro. J Trauma Acute Care Surg 2022; 92:159-166. [PMID: 34538821 PMCID: PMC8692352 DOI: 10.1097/ta.0000000000003410] [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] [Indexed: 01/03/2023]
Abstract
BACKGROUND Severe injury predisposes patients to trauma-induced coagulopathy, which may be subdivided by the state of fibrinolysis. Systemic hyperfibrinolysis (HF) occurs in approximately 25% of these patients with mortality as high as 70%. Severe injury also causes the release of numerous intracellular proteins, which may affect coagulation, one of which is hemoglobin, and hemoglobin substitutes induce HF in vitro. We hypothesize that the α-globin chain of hemoglobin potentiates HF in vitro by augmenting plasmin activity. METHODS Proteomic analysis was completed on a pilot study of 30 injured patients before blood component resuscitation, stratified by their state of fibrinolysis, plus 10 healthy controls. Different concentrations of intact hemoglobin A, the α- and β-globin chains, or normal saline (controls) were added to whole blood, and tissue plasminogen activator (tPA)-challenged thrombelastography was used to assess the degree of fibrinolysis. Interactions with plasminogen (PLG) were evaluated using surface plasmon resonance. Tissue plasminogen activator-induced plasmin activity was evaluated in the presence of the α-globin chain. RESULTS Only the α- and β-globin chains increased in HF patients (p < 0.01). The α-globin chain but not hemoglobin A or the β-globin chain decreased the reaction time and significantly increased lysis time 30 on citrated native thrombelastographies (p < 0.05). The PLG and α-globin chain had interaction kinetics similar to tPA:PLG, and the α-globin chain increased tPA-induced plasmin activity. CONCLUSIONS The α-globin chain caused HF in vitro by binding to PLG and augmenting plasmin activity and may represent a circulating "moonlighting" mediator released by the tissue damage and hemorrhagic shock inherent to severe injury. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Alexander P Morton
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Jamie B Hadley
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
| | - Arsen Ghasabyan
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Marguerite R. Kelher
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Ernest E Moore
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Surgery, Denver Health Medical Center, Vitalant Mountain Division, Denver, CO
| | - Shaun Bevers
- Department of Biochemistry and Molecular Genetics, School of Medicine University of Colorado Denver, Aurora, CO
| | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, School of Medicine University of Colorado Denver, Aurora, CO
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, School of Medicine University of Colorado Denver, Aurora, CO
| | - Mitchell S Cohen
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
| | - Anirban Banerjee
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
| | - Christopher C Silliman
- Department of Surgery, School of Medicine University of Colorado Denver, Aurora, CO
- Department of Pediatrics, School of Medicine University of Colorado Denver, Aurora, CO
- Vitalant Research Institute, Vitalant Mountain Division, Denver, CO
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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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Abstract
Fibrinogen plays a fundamental role in coagulation through its support for platelet aggregation and its conversion to fibrin. Fibrin stabilizes clots and serves as a scaffold and immune effector before being broken down by the fibrinolytic system. Given its importance, abnormalities in fibrin(ogen) and fibrinolysis result in a variety of disorders with hemorrhagic and thrombotic manifestations. This review summarizes (i) the basic elements of fibrin(ogen) and its role in coagulation and the fibrinolytic system; (ii) the laboratory evaluation for fibrin(ogen) disorders, including the use of global fibrinolysis assays; and (iii) the management of congenital and acquired disorders of fibrinogen and fibrinolysis.
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Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, University of Alabama at Birmingham, 1720 2nd Avenue South, NP 2503, Birmingham, AL 35294, USA
| | - Alisa S Wolberg
- UNC Department of Pathology and Laboratory Medicine, UNC Blood Research Center, 8018A Mary Ellen Jones Building, CB7035, Chapel Hill, NC 27599-7035, USA
| | - Ming Yeong Lim
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, 2000 Circle Hope Drive, Room 4126, Salt Lake City, UT 84112, USA.
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Brill JB, Brenner M, Duchesne J, Roberts D, Ferrada P, Horer T, Kauvar D, Khan M, Kirkpatrick A, Ordonez C, Perreira B, Priouzram A, Cotton BA. The Role of TEG and ROTEM in Damage Control Resuscitation. Shock 2021; 56:52-61. [PMID: 33769424 PMCID: PMC8601668 DOI: 10.1097/shk.0000000000001686] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/05/2019] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
ABSTRACT Trauma-induced coagulopathy is associated with very high mortality, and hemorrhage remains the leading preventable cause of death after injury. Directed methods to combat coagulopathy and attain hemostasis are needed. The available literature regarding viscoelastic testing, including thrombelastography (TEG) and rotational thromboelastometry (ROTEM), was reviewed to provide clinically relevant guidance for emergency resuscitation. These tests predict massive transfusion and developing coagulopathy earlier than conventional coagulation testing, within 15 min using rapid testing. They can guide resuscitation after trauma, as well. TEG and ROTEM direct early transfusion of fresh frozen plasma when clinical gestalt has not activated a massive transfusion protocol. Reaction time and clotting time via these tests can also detect clinically significant levels of direct oral anticoagulants. Slowed clot kinetics suggest the need for transfusion of fibrinogen via concentrates or cryoprecipitate. Lowered clot strength can be corrected with platelets and fibrinogen. Finally, viscoelastic tests identify fibrinolysis, a finding associated with significantly increased mortality yet one that no conventional coagulation test can reliably detect. Using these parameters, guided resuscitation begins within minutes of a patient's arrival. A growing body of evidence suggests this approach may improve survival while reducing volumes of blood products transfused.
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Affiliation(s)
- Jason B. Brill
- Department of Surgery, University of Texas Health Science Center, Houston, Texas
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Juan Duchesne
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Derek Roberts
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Paula Ferrada
- VCU Surgery Trauma, Critical Care and Emergency Surgery, Richmond, Virginia
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Science Örebro University Hospital and University, Örebro, Sweden
| | - David Kauvar
- Vascular Surgery Service, San Antonio Military Medical Center, San Antonio, Texas
| | - Mansoor Khan
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, UK
| | - Andrew Kirkpatrick
- Regional Trauma Services Foothills Medical Centre, Calgary, Alberta, Canada
- Departments of Surgery, Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
- Canadian Forces Health Services, Calgary, Alberta, Canada
| | - Carlos Ordonez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Universidad del Valle, Valle, Colombia
| | - Bruno Perreira
- Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Artai Priouzram
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
| | - Bryan A. Cotton
- Department of Surgery, University of Texas Health Science Center, Houston, Texas
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Laubscher GJ, Lourens PJ, Venter C, Kell DB, Pretorius E. TEG ®, Microclot and Platelet Mapping for Guiding Early Management of Severe COVID-19 Coagulopathy. J Clin Med 2021; 10:jcm10225381. [PMID: 34830660 PMCID: PMC8621180 DOI: 10.3390/jcm10225381] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 02/08/2023] Open
Abstract
An important component of severe COVID-19 disease is virus-induced endothelilitis. This leads to disruption of normal endothelial function, initiating a state of failing normal clotting physiology. Massively increased levels of von Willebrand Factor (VWF) lead to overwhelming platelet activation, as well as activation of the enzymatic (intrinsic) clotting pathway. In addition, there is an impaired fibrinolysis, caused by, amongst others, increased levels of alpha-(2) antiplasmin. The end result is hypercoagulation (proven by thromboelastography® (TEG®)) and reduced fibrinolysis, inevitably leading to a difficult-to-overcome hypercoagulated physiological state. Platelets in circulation also plays a significant role in clot formation, but they themselves may also drive hypercoagulation when they are overactivated due to the interactions of their receptors with the endothelium, immune cells or circulating inflammatory molecules. From the literature it is clear that the role of platelets in severely ill COVID-19 patients has been markedly underestimated or even ignored. We here highlight the value of early management of severe COVID-19 coagulopathy as guided by TEG®, microclot and platelet mapping. We also argue that the failure of clinical trials, where the efficacy of prophylactic versus therapeutic clexane (low molecular weight heparin (LMWH)) were not always successful, which may be because the significant role of platelet activation was not taken into account during the planning of the trial. We conclude that, because of the overwhelming alteration of clotting, the outcome of any trial evaluating an any single anticoagulant, including thrombolytic, would be negative. Here we suggest the use of the degree of platelet dysfunction and presence of microclots in circulation, together with TEG®, might be used as a guideline for disease severity. A multi-pronged approach, guided by TEG® and platelet mapping, would be required to maintain normal clotting physiology in severe COVID-19 disease.
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Affiliation(s)
| | | | - Chantelle Venter
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch 7602, South Africa;
| | - Douglas B Kell
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch 7602, South Africa;
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZB, UK
- The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark
- Correspondence: (D.B.K.); (E.P.)
| | - Etheresia Pretorius
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch 7602, South Africa;
- Correspondence: (D.B.K.); (E.P.)
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Keith MT, Chalifoux NV, Buriko Y. The effect of analytical temperature on thromboelastography tracings in dogs. J Vet Diagn Invest 2021; 34:10-14. [PMID: 34515588 DOI: 10.1177/10406387211042922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Viscoelastic testing methods such as thromboelastography (TEG) are becoming increasingly available to veterinarians in a clinical setting. TEG is useful in determining therapeutic transfusion needs and assessing global abnormalities of hemostasis of patients, given that it provides a more comprehensive assessment of coagulation than traditional tests. TEG is standardly performed at 37°C, which is considered a normal body temperature for human patients; however, 37°C is lower than normal body temperature for most canine patients. In an in vitro study, we investigated the potential effect that this difference in body temperature and test temperature might have on TEG results. Citrated blood samples were collected from clinically normal, as well as sick, dogs with various body temperatures. Samples were analyzed concurrently at the patient's body temperature and at 37°C. There was very high correlation between TEG performed at body temperature and at 37°C for R (min) and MA (mm), high correlation for K (min) and alpha angle (deg), and moderate correlation for LY30 (%) and LY60 (%). For canine patients with normal to mildly abnormal body temperatures, performance of TEG at the standard 37°C is acceptable.
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Affiliation(s)
- Marie T Keith
- Department of Clinical Sciences and Advanced Medicine, Veterinary Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nolan V Chalifoux
- Department of Clinical Sciences and Advanced Medicine, Veterinary Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Yekaterina Buriko
- Department of Clinical Sciences and Advanced Medicine, Veterinary Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Abstract
The main goal of perioperative coagulation monitoring is to improve safety of patients undergoing surgical procedures. Various conditions can affect the coagulation system during surgery and bleeding. The value of traditional standard coagulation tests is limited in detecting hemostatic dysfunctions and they are particularly ineffective in diagnosing hyperfibrinolysis. This article reports on key issues and pathophysiologic changes that affect the hemostatic system in the perioperative setting. Values of preoperative coagulation tests are discussed and the basic principles for point-of-care coagulation devices, including platelet analyzers and their clinical use, are evaluated.
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Affiliation(s)
- Christian Fenger-Eriksen
- Department of Anaesthesiology, Aarhus University Hospital, Palle Juul Jensens Boulevard, Aarhus N DK-8200, Denmark.
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Bardes JM, Grabo DJ, Wen S, Wilson A. Pathologic Fibrinolysis is More Common in a Rural Trauma Setting. Am Surg 2021; 87:1112-1117. [PMID: 33317318 PMCID: PMC8203746 DOI: 10.1177/0003134820973726] [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] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Fibrinolysis (lysis) has been extensively studied in trauma patients. Many studies on the distribution of lysis phenotype have been conducted in setting with short prehospital time. This study aimed to evaluate the distribution of lysis phenotypes in a population with prolonged prehospital times in a rural environment. METHODS A retrospective study was performed at an American College of Surgeons-verified level 1 trauma center, serving a large rural population. Full trauma team activations from January 1, 2017 to August 31, 2018 were evaluated, and all patients with an ISS>15 analyzed. Thromboelastography was routinely performed on all participants on arrival. Lysis phenotypes were classified based on LY30 results: shutdown (≤.8%), physiologic (.9-2.9%), and hyper (>2.9%). RESULTS 259 patients were evaluated, 134 (52%) presented direct from the scene. For scene patients, lysis distribution was 24% physiologic, 49% shutdown, and 27% hyper. Transferred patients demonstrated a reduction in physiologic lysis to 14% (P = .03), shutdown present in 66%, and hyper in 20%. Empiric prehospital tranexamic acid was given to 18 patients, physiologic lysis was present in 6%, shutdown 72%, and hyper 22%; this increase was not statistically significant (P = .5). CONCLUSION Fibrinolysis phenotypes are not consistent across all trauma populations. This study showed rural trauma patients had a significantly increased rate of pathologic lysis. This was consistent for scene and transfer patients who received care at another facility prior to arrival for definitive care. Future studies to evaluate the factors influencing these differences are warranted.
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Affiliation(s)
- James M. Bardes
- Department of Surgery, Division of Trauma, Acute Care Surgery and Surgical Critical Care, West Virginia University, Morgantown, WV, USA
| | - Daniel J. Grabo
- Department of Surgery, Division of Trauma, Acute Care Surgery and Surgical Critical Care, West Virginia University, Morgantown, WV, USA
| | - Sijin Wen
- School of Public Health, Department of Biostatics, West Virginia University, Morgantown, WV, USA
| | - Alison Wilson
- Department of Surgery, Division of Trauma, Acute Care Surgery and Surgical Critical Care, West Virginia University, Morgantown, WV, USA
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Vigneshwar NG, Moore HB, Moore EE. Trauma-Induced Coagulopathy: Diagnosis and Management in 2020. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00438-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Toelle LJ, Hatton GE, Refuerzo JS, Wade CE, Cotton BA, Kao LS. Hypercoagulability in pregnant trauma patients. Trauma Surg Acute Care Open 2021; 6:e000714. [PMID: 34250259 PMCID: PMC8230999 DOI: 10.1136/tsaco-2021-000714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Circulating hormones affect coagulopathy in pregnancy and after trauma. The hemostatic profile of pregnant women after injury has not been characterized. We hypothesized that injured pregnant females would present with an initial thrombelastography (TEG) reflecting a more hypercoagulable profile and a higher incidence of venous thromboembolic events (VTE) when compared with non-pregnant females and males.
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Affiliation(s)
- Lisa J Toelle
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Gabrielle E Hatton
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jerrie S Refuerzo
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bryan A Cotton
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Lillian S Kao
- Surgery, McGovern Medical School at University of Texas Health Science Center at Houston, Houston, Texas, USA
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Anderson TN, Farrell DH, Rowell SE. Fibrinolysis in Traumatic Brain Injury: Diagnosis, Management, and Clinical Considerations. Semin Thromb Hemost 2021; 47:527-537. [PMID: 33878779 DOI: 10.1055/s-0041-1722970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Posttraumatic coagulopathy involves disruption of both the coagulation and fibrinolytic pathways secondary to tissue damage, hypotension, and inflammatory upregulation. This phenomenon contributes to delayed complications after traumatic brain injury (TBI), including intracranial hemorrhage progression and systemic disseminated intravascular coagulopathy. Development of an early hyperfibrinolytic state may result in uncontrolled bleeding and is associated with increased mortality in patients with TBI. Although fibrinolytic assays are not routinely performed in the assessment of posttraumatic coagulopathy, circulating biomarkers such as D-dimer and fibrin degradation products have demonstrated potential utility in outcome prediction. Unfortunately, the relatively delayed nature of these tests limits their clinical utility. In contrast, viscoelastic tests are able to provide a rapid global assessment of coagulopathy, although their ability to reliably identify disruptions in the fibrinolytic cascade remains unclear. Limited evidence supports the use of hypertonic saline, cryoprecipitate, and plasma to correct fibrinolytic disruption; however, some studies suggest more harm than benefit. Recently, early use of tranexamic acid in patients with TBI and confirmed hyperfibrinolysis has been proposed as a strategy to further improve clinical outcomes. Moving forward, further delineation of TBI phenotypes and the clinical implications of fibrinolysis based on phenotypic variation is needed. In this review, we summarize the clinical aspects of fibrinolysis in TBI, including diagnosis, treatment, and clinical correlates, with identification of targeted areas for future research efforts.
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Affiliation(s)
- Taylor N Anderson
- School of Medicine, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - David H Farrell
- School of Medicine, Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - Susan E Rowell
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Prittie J. The role of cryoprecipitate in human and canine transfusion medicine. J Vet Emerg Crit Care (San Antonio) 2021; 31:204-214. [PMID: 33751762 DOI: 10.1111/vec.13034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/27/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the current role of cryoprecipitate in human and canine transfusion medicine. DATA SOURCES Human and veterinary scientific reviews and original studies found using PubMed and CAB Abstract search engines were reviewed. HUMAN DATA SYNTHESIS In the human critical care setting, cryoprecipitate is predominantly used for fibrinogen replenishment in bleeding patients with acute traumatic coagulopathy. Other coagulopathic patient cohorts for whom cryoprecipitate is recommended include those undergoing cardiovascular or obstetric procedures or patients bleeding from advanced liver disease. Preferential selection of cryoprecipitate versus fibrinogen concentrate (when available) is currently being investigated. Also a matter of ongoing debate is whether to administer this product as part of a fixed-dose massive hemorrhage protocol or to incorporate it into a goal-directed transfusion algorithm applied to the individual bleeding patient. VETERINARY DATA SYNTHESIS Although there are sporadic reports of the use of cryoprecipitate in dogs with heritable coagulopathies, there are few to no data pertaining to its use in acquired hypofibrinogenemic states. Low fibrinogen in dogs (as in people) has been documented with acute traumatic coagulopathy, advanced liver disease, and disseminated intravascular coagulation. Bleeding secondary to these hypocoagulable states may be amenable to cryoprecipitate therapy. Indications for preferential selection of cryoprecipitate (versus fresh frozen plasma) remain to be determined. CONCLUSIONS In the United States, cryoprecipitate remains the standard of care for fibrinogen replenishment in the bleeding human trauma patient. Its preferential selection for this purpose is the subject of several ongoing human clinical trials. Timely incorporation of cryoprecipitate into the transfusion protocol of the individual bleeding patient with hypofibrinogenemia may conserve blood products, mitigate adverse transfusion-related events, and improve patient outcomes. Cryoprecipitate is readily available, effective, and safe for use in dogs. The role of this blood product in clinical canine patients with acquired coagulopathy remains unknown.
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Affiliation(s)
- Jennifer Prittie
- Department of Emergency and Critical Care, Animal Medical Center, New York, New York
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Plasmin thrombelastography rapidly identifies trauma patients at risk for massive transfusion, mortality, and hyperfibrinolysis: A diagnostic tool to resolve an international debate on tranexamic acid? J Trauma Acute Care Surg 2021; 89:991-998. [PMID: 33230046 DOI: 10.1097/ta.0000000000002941] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Trauma patients with hyperfibrinolysis and depletion of fibrinolytic inhibitors (DFIs) measured by thrombelastography (TEG) gain clot strength with TXA, but TEG results take nearly an hour. We aimed to develop an assay, plasmin TEG (P-TEG), to more expeditiously stratify risk for massive transfusion (MT), mortality, and hyperfibrinolysis. METHODS Trauma patients (N = 148) were assessed using TEG assays without exogenous additives (rapid/native), with exogenous plasmin (P-TEG) or tissue plasminogen activator (tPA TEG). The plasmin dose used does not effect healthy-control clot lysis 30 minutes after maximum amplitude (LY30) but causes shortened reaction time (R time) relative to native TEG (P-TEG R time < native TEG R time considered P-TEG negative). If P-TEG R time is greater than or equal to native TEG R time, the patient was considered P-TEG positive. Each assay's ability to predict MT, mortality, and (risk for) hyperfibrinolysis was determined. χ and Mann-Whitney U tests were used to compare categorical and continuous variables, respectively. Results were reported as median ± interquartile range or n (%). RESULTS Plasmin TEG provided results faster than all other assays (4.7 ± 2.5-9.1 minutes), approximately 11-fold faster than rapid-TEG (rTEG) LY30 (54.2 ± 51.1-58.1 minutes; p < 0.001). Plasmin TEG-positive patients had greater than fourfold higher MT rate (30% vs. 7%; p = 0.0015) with an area under the receiver operating characteristic curve of 0.686 (p = 0.028), greater than fourfold higher 24-hour mortality (33.3% vs. 7.8%; p = 0.0177), greater than twofold higher 30-day mortality (35% vs. 16.4%; p = 0.0483), higher rates of DFI (55% vs. 18%; p < 0.001), and a trend toward elevated D-dimer (19.9 vs. 3.3 μg/mL; p = 0.14). Plasmin TEG was associated with hyperfibrinolysis on rTEG LY30 at the 7.6% threshold (p = 0.04) but not the 3% threshold (p = 0.40). Plasmin TEG performed best in relation to DFI, with a positive predictive value of 58% and negative predictive value of 81%. When combined with tPA TEG time to maximum amplitude, P-TEG outperformed rTEG LY30 for predicting MT (area under the receiver operating characteristic curve, 0.811 vs. 0.708). CONCLUSION Within 5 minutes, P-TEG can stratify patients at highest risk for MT, mortality, and risk for hyperfibrinolysis. In composite with tPA TEG time to maximum amplitude, P-TEG outperforms rTEG LY30 for predicting MT and does so four times faster (12.7 vs. 54.1 minutes). The rapid results of P-TEG may be useful for those who practice selective TXA administration to maximize TXA's time-dependent efficacy. LEVEL OF EVIDENCE Diagnostic test, level V.
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Pavoni V, Gianesello L, Pazzi M, Horton A, Suardi LR. Derangement of the coagulation process using subclinical markers and viscoelastic measurements in critically ill patients with coronavirus disease 2019 pneumonia and non-coronavirus disease 2019 pneumonia. Blood Coagul Fibrinolysis 2021; 32:80-86. [PMID: 33196505 DOI: 10.1097/mbc.0000000000000971] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Systemic coagulation abnormalities including clotting activation and inhibition of anticoagulant factors have been observed in patients with pneumonia. In severe coronavirus disease 2019 (COVID-19) the alteration of coagulation parameters was associated with poor prognosis. We evaluated the difference in coagulopathy between critically ill patients with COVID-19 pneumonia (COVID group) and non-COVID-19 pneumonia (non-COVID group), using traditional coagulation markers and rotational thromboelastometry (ROTEM). Standard laboratory and ROTEM parameters were evaluated in 45 patients (20 COVID group patients and 25 non-COVID group patients) at time of admission to the Intensive Care Unit (ICU) (T0) and at 5 (T5) and 10 days (T10) later. In all evaluations times, platelet count was found higher in COVID group rather than in non-COVID group. At T0, COVID group revealed a fibrinogen value greater than non-COVID group. d-Dimer values were high in both groups and they were not statistically different. At T0 COVID group showed a significant reduction of clot formation time in INTEM and in EXTEM and a significant increase of maximum clot firmness in INTEM, EXTEM and FIBTEM respect to non-COVID group. Moreover, COVID group demonstrated a coagulability state with ROTEM profiles higher than non-COVID group at T5 and T10. Coagulation profiles showed that critically ill patients with COVID-19 pneumonia are characterized by a higher coagulable state than others; this greater procoagulative state persists over time.
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Affiliation(s)
- Vittorio Pavoni
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care, Santa Maria Annunziata Hospital
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, University-Hospital Careggi, Florence, Italy
| | - Maddalena Pazzi
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care, Santa Maria Annunziata Hospital
| | - Andrew Horton
- School of Dentistry, University of Utah Health, Salt Lake City, Utah, USA
| | - Lorenzo R Suardi
- Infectious Diseases Department, Santa Maria Annunziata Hospital, Florence, Italy
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Farrell MS, Moore EE, Thomas AV, Coleman JR, Thomas S, Vande Lune S, Marconi T, Cohen MJ, Chapman MP, Moore HB, Walsh MM, Sixta S. "Death Diamond" Tracing on Thromboelastography as a Marker of Poor Survival After Trauma. Am Surg 2021; 88:1689-1693. [PMID: 33629880 DOI: 10.1177/0003134821998684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Improvements in health care innovations have resulted in an enhanced ability to extend patient viability. As a consequence, resources are being increasingly utilized at an unsustainable level. As we implement novel treatments, identifying futility should be a focus. The "death diamond" (DD) is a unique thrombelastography (TEG) tracing that is indicative of failure of the coagulation system, with a mortality rate exceeding 90%. The purpose of this study was to determine if the DD was a consistent marker of poor survival in a multicenter study population. We hypothesize that the DD, while an infrequent occurrence, predicts poor survival and can be used to stratify patients in whom resuscitation efforts are futile. METHODS A retrospective multi-institutional study of trauma patients presenting with TEG DDs between 8/2008 and 12/2018 at four American College of Surgeons trauma centers was completed. Demographics, injury mechanisms, TEG results, management, and survival were examined. RESULTS A total of 50 trauma patients presented with DD tracings, with a 94% (n = 47) mortality rate. Twenty-six (52%) patients received a repeat TEG with 10 patients re-demonstrating the DD tracing. There was 100% mortality in patients with serial DD tracings. The median use of total blood products was 18 units (interquartile range 6, 34.25) per patient. DISCUSSION The DD is highly predictive of trauma-associated mortality. This multicenter study highlights that serial DDs may represent a possible biomarker of futility.
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Affiliation(s)
- Michael S Farrell
- Departments of Trauma, Surgery, and Critical Care Medicine, 5973Christiana Care Health Services, Wilmington, DE, USA
| | - Ernest E Moore
- Department of Surgery, 129263University of Colorado-Anschutz Medical Campus, Aurora, CO, USA.,Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Anthony V Thomas
- 158720Notre Dame Campus, Indiana University School of Medicine, South Bend, IN, USA.,Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Julia R Coleman
- Department of Surgery, 129263University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Scott Thomas
- Memorial Trauma Center, Memorial Hospital, South Bend, IN, USA
| | - Stefani Vande Lune
- Emergency Medicine Department, Navy Medicine Readiness and Training Command, Portsmouth, VA, USA
| | - Thomas Marconi
- Departments of Trauma, Surgery, and Critical Care Medicine, 5973Christiana Care Health Services, Wilmington, DE, USA
| | - Mitchell J Cohen
- Department of Surgery, 129263University of Colorado-Anschutz Medical Campus, Aurora, CO, USA.,Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Michael P Chapman
- Department of Radiology, University of Colorado-Denver, Denver, CO, USA
| | - Hunter B Moore
- Department of Surgery, 129263University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Mark M Walsh
- 158720Notre Dame Campus, Indiana University School of Medicine, South Bend, IN, USA.,Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Sherry Sixta
- Departments of Trauma, Surgery, and Critical Care Medicine, 5973Christiana Care Health Services, Wilmington, DE, USA
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Tranexamic acid administration in the field does not affect admission thromboelastography after traumatic brain injury. J Trauma Acute Care Surg 2021; 89:900-907. [PMID: 33105308 DOI: 10.1097/ta.0000000000002932] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND No Food and Drug Administration-approved medication improves outcomes following traumatic brain injury (TBI). A forthcoming clinical trial that evaluated the effects of two prehospital tranexamic acid (TXA) dosing strategies compared with placebo demonstrated no differences in thromboelastography (TEG) values. We proposed to explore the impact of TXA on markers of coagulation and fibrinolysis in patients with moderate to severe TBI. METHODS Data were extracted from a placebo-controlled clinical trial in which patients 15 years or older with TBI (Glasgow Coma Scale, 3-12) and systolic blood pressure of ≥90 mm Hg were randomized prehospital to receive placebo bolus/placebo infusion (placebo), 1 g of TXA bolus/1 g of TXA infusion (bolus maintenance), or 2 g of TXA bolus/placebo infusion (bolus only). Thromboelastography was performed, and coagulation measures including prothrombin time, activated partial thromboplastin time, international ratio, fibrinogen, D-dimer, plasmin-antiplasmin (PAP), thrombin antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor 1 were quantified at admission and 6 hours later. RESULTS Of 966 patients receiving study drug, 700 had laboratory tests drawn at admission and 6 hours later. There were no statistically significant differences in TEG values, including LY30, between groups (p > 0.05). No differences between prothrombin time, activated partial thromboplastin time, international ratio, fibrinogen, thrombin antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor 1 were demonstrated across treatment groups. Concentrations of D-dimer in TXA treatment groups were less than placebo at 6 hours (p < 0.001). Concentrations of PAP in TXA treatment groups were less than placebo on admission (p < 0.001) and 6 hours (p = 0.02). No differences in D-dimer and PAP were observed between bolus maintenance and bolus only. CONCLUSION While D-dimer and PAP levels reflect a lower degree of fibrinolysis following prehospital administration of TXA when compared with placebo in a large prehospital trial of patients with TBI, TEG obtained on admission and 6 hours later did not demonstrate any differences in fibrinolysis between the two TXA dosing regimens and placebo. LEVEL OF EVIDENCE Diagnostic test, level III.
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Richards JE, Fedeles BT, Chow JH, Morrison JJ, Renner C, Trinh AT, Schlee CS, Koerner K, Grissom TE, Betzold RD, Scalea TM, Kozar RA. Is Tranexamic Acid Associated With Mortality or Multiple Organ Failure Following Severe Injury? Shock 2021; 55:55-60. [PMID: 33337787 DOI: 10.1097/shk.0000000000001608] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) administration is recommended in severely injured trauma patients. We examined TXA administration, admission fibrinolysis phenotypes, and clinical outcomes following traumatic injury and hypothesized that TXA was associated with increased multiple organ failure (MOF). METHODS Two-year, single-center, retrospective investigation. Inclusion criteria were age ≥ 18 years, Injury Severity Score (ISS) >16, admitted from scene of injury, thromboelastography within 30 min of arrival. Fibrinolysis was evaluated by lysis at 30 min (LY30) and fibrinolysis phenotypes were defined as: Shutdown: LY30 ≤ 0.8%, Physiologic: LY30 0.81-2.9%, Hyperfibrinolysis: LY30 ≥ 3.0%. Primary outcomes were 28-day mortality and MOF. The association of TXA with mortality and MOF was assessed among the entire study population and in each of the fibrinolysis phenotypes. RESULTS Four hundred twenty patients: 144/420 Shutdown (34.2%), 96/420 Physiologic (22.9%), and 180/410 Hyperfibrinolysis (42.9%). There was no difference in 28-day mortality by TXA administration among the entire study population (P = 0.52). However, there was a significant increase in MOF in patients who received TXA (11/46, 23.9% vs 16/374, 4.3%; P < 0.001). TXA was associated MOF (OR: 3.2, 95% CI 1.2-8.9), after adjusting for confounding variables. There was no difference in MOF in patients who received TXA in the Physiologic (1/5, 20.0% vs 7/91, 7.7%; P = 0.33) group. There was a significant increase in MOF among patients who received TXA in the Shutdown (3/11, 27.3% vs 5/133, 3.8%; P = 0.001) and Hyperfibrinolysis (7/30, 23.3% vs 5/150, 3.3%; P = 0.001) groups. CONCLUSIONS Administration of TXA following traumatic injury was associated with MOF in the fibrinolysis shutdown and hyperfibrinolysis phenotypes and warrants continued evaluation.
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Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Benjamin T Fedeles
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan H Chow
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan J Morrison
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Corinne Renner
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Anthony T Trinh
- University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Ken Koerner
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Richard D Betzold
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Thomas M Scalea
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Rosemary A Kozar
- Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
- University of Maryland School of Medicine, Baltimore, Maryland
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Michelson EA, Cripps MW, Ray B, Winegar DA, Viola F. Initial clinical experience with the Quantra QStat System in adult trauma patients. Trauma Surg Acute Care Open 2020; 5:e000581. [PMID: 33178896 PMCID: PMC7640591 DOI: 10.1136/tsaco-2020-000581] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/24/2020] [Accepted: 10/14/2020] [Indexed: 12/22/2022] Open
Abstract
Background Whole blood viscoelastic testing (VET) devices are routinely used in a variety of clinical settings to assess hemostasis. The Quantra QStat System is a cartridge-based point of care VET device that measures changes in clot stiffness during coagulation and fibrinolysis using ultrasound detection of resonance. The objective of this study was to assess the ability of the Quantra QStat System to detect coagulopathies in trauma patients. Methods A multicenter observational study was conducted on adult subjects at two level 1 trauma centers. For each subject, whole blood samples were drawn upon arrival to the emergency department and again, in some cases, after administration of blood products and/or antifibrinolytics. Samples were analyzed on the Quantra in parallel to ROTEM delta. The QStat cartridge provides measures of Clot Time (CT), Clot Stiffness (CS), Fibrinogen and Platelet Contributions to clot stiffness (FCS and PCS), and Clot Stability to Lysis (CSL). Data analyses included linear regression of Quantra and ROTEM parameters and an assessment of the concordance of the two devices for the assessment of hyperfibrinolysis. Results A total of 56 patients were analyzed. 42% of samples had a low QStat CS value suggestive of an hypocoagulable state. The low stiffness values could be attributed to either low PCS, FCS or combination. Additionally, 13% of samples showed evidence of hyperfibrinolysis based on the QStat CSL parameter. Samples analyzed with ROTEM assays showed a lower prevalence of low CS and hyperfibrinolysis based on EXTEM and FIBTEM results. The correlation of CS, FCS and CT versus equivalent ROTEM parameters was strong with r-values of 0.83, 0.79 and 0.79, respectively. Discussion This first clinical experience with the Quantra in trauma patients showed that the QStat Cartridge was strongly correlated with ROTEM parameters and that it could detect coagulopathies associated with critical bleeding. Level of evidence Diagnostic test, Level II.
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Affiliation(s)
- Edward A Michelson
- Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Michael W Cripps
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Bradford Ray
- University Medical Center of El Paso, El Paso, Texas, USA
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Arnolds DE, Scavone BM. Thromboelastographic Assessment of Fibrinolytic Activity in Postpartum Hemorrhage: A Retrospective Single-Center Observational Study. Anesth Analg 2020; 131:1373-1379. [PMID: 33079858 DOI: 10.1213/ane.0000000000004796] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Postpartum hemorrhage is a leading cause of maternal mortality. Antifibrinolytic therapy has the potential to influence outcomes in postpartum hemorrhage, but the incidence of elevated fibrinolytic activity in postpartum hemorrhage is unknown. METHODS We retrospectively reviewed thromboelastography (TEG) results obtained for postpartum hemorrhage from 118 deliveries at The University of Chicago. TEG results were obtained as part of our postpartum hemorrhage protocol when blood loss exceeded 500 mL after vaginal delivery or 1000 mL after cesarean delivery. Our primary outcome was the incidence of elevated fibrinolytic activity, which we predefined as clot lysis ≥3% at 30 minutes (Ly30) on kaolin TEG. Platelet-mediated clot retraction can also lead to an elevated Ly30 on kaolin TEG. Therefore, to distinguish between fibrinolysis and clot retraction, we evaluated clot lysis using functional fibrinogen TEG, which contains a platelet inhibitor. We considered a kaolin TEG Ly30 ≥3% in conjunction with a nonzero functional fibrinogen TEG Ly30 suggestive of elevated fibrinolytic activity. We also recorded quantitative blood loss, primary etiology of hemorrhage, standard laboratory measurements of coagulation, and demographic and obstetric characteristics of the study population. RESULTS The median kaolin TEG Ly30 was 0.2% (interquartile range: 0%-0.8%). Fifteen of 118 women (12.7%; 95% confidence interval, 7.9%-19.9%) had kaolin TEG Ly30 values ≥3%. Of 15 patients with elevated Ly30 values, functional fibrinogen TEG Ly30 was available for 13, of which none demonstrated detectable clot lysis. CONCLUSIONS Our observation that none of the patients in our sample with kaolin TEG Ly30 values ≥3% had a nonzero functional fibrinogen TEG Ly30 value suggests that the observed elevations in kaolin TEG Ly30 may have been secondary to platelet-mediated clot retraction as opposed to fibrinolysis. Platelet-mediated clot retraction should be distinguished from fibrinolysis when assayed using viscoelastic techniques in postpartum hemorrhage. Further research is necessary to determine the optimal methods to assess fibrinolytic activity in postpartum hemorrhage.
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Affiliation(s)
| | - Barbara M Scavone
- From the Departments of Anesthesia and Critical Care and
- Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
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Iannucci C, Dirkmann D, Howard J, Adamik KN. A prospective randomized open-label trial on the comparative effects of 6% hydroxyethyl starch 130/0.4 versus polyionic isotonic crystalloids on coagulation parameters in dogs with spontaneous hemoperitoneum. J Vet Emerg Crit Care (San Antonio) 2020; 31:32-42. [PMID: 33108052 DOI: 10.1111/vec.13018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 03/17/2019] [Accepted: 04/23/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To evaluate the effects of 6% hydroxyethyl starch 130/0.4 (HES) and a polyionic isotonic crystalloid (CRYS) on standard coagulation tests and rotational thromboelastometry (ROTEM) in dogs with spontaneous hemoperitoneum (SHP). DESIGN Prospective randomized open-label clinical study. SETTING University teaching hospital. ANIMALS Forty-two client-owned dogs presented with SHP. INTERVENTIONS Dogs diagnosed with SHP and hypovolemic shock were randomly allocated to receive HES (10 mL/kg, n = 22) or CRYS (30 mL/kg, n = 20) intravenously over 20 minutes for hemodynamic stabilization. MEASUREMENTS AND MAIN RESULTS Parameters measured before (T0 ) and after (T1 ) treatment were HCT, platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen concentrations, and extrinsic activated (EXTEM), intrinsic activated (INTEM), and extrinsic activated with platelet inhibition ROTEM assays. Data were analyzed as absolute values and as the percentage change from T0 to T1 . No significant differences between groups were detected in any variable at T0 , and for HCT, platelet counts, prothrombin time, activated thromboplastin time, and fibrinogen concentrations at T1 . Clot formation time in EXTEM was significantly prolonged (P = 0.037), and maximum clot firmness was significantly decreased (P = 0.038) in the HES group compared to the CRYS group at T1 . The percentage change in EXTEM clotting time (P = 0.012) and INTEM clot formation time (P = 0.031) was greater after HES than CRYS. Lysis indices remained at 100% for all ROTEM assays in both groups. CONCLUSION Compared to a 3-fold volume of CRYS, administration of HES was associated with impairment in ROTEM parameters in dogs with SHP, but no evidence of hyperfibrinolysis was detected.
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Affiliation(s)
- Claudia Iannucci
- Division of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Daniel Dirkmann
- Clinic for Anesthesiology and Intensive Care, Essen University Hospital, Essen, Germany
| | - Judith Howard
- Clinical Diagnostic Laboratory, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Katja N Adamik
- Division of Small Animal Emergency and Critical Care, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Bern, Bern, Switzerland
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Spasiano A, Barbarino C, Marangone A, Orso D, Trillò G, Giacomello R, Bove T, Della Rocca G. Early thromboelastography in acute traumatic coagulopathy: an observational study focusing on pre-hospital trauma care. Eur J Trauma Emerg Surg 2020; 48:431-439. [PMID: 32929548 PMCID: PMC8825617 DOI: 10.1007/s00068-020-01493-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/04/2020] [Indexed: 01/20/2023]
Abstract
Background Major brain injury and uncontrolled blood loss remain the primary causes of early trauma-related mortality. One-quarter to one-third of trauma patients exhibit trauma-induced coagulopathy (TIC). Thromboelastometry (ROTEM) and thrombelastography (TEG) are valuable alternatives to standard coagulation testing, providing a more comprehensive overview of the coagulation process. Purpose Evaluating thromboelastographic profile, the incidence of fibrinolysis (defined as Ly30 > 3%) in severe trauma patients, and factors influencing pathological coagulation pattern. Methods Prospective observational 2 years cohort study on severe trauma patients assisted by Helicopter Emergency Medical System (HEMS) and Level 1 Trauma Center, in a tertiary referral University Hospital. Results Eighty three patients were enrolled, mean NISS (new injury severity score) 36 (± 13). Mean R value decreased from 7.25 (± 2.6) to 6.19 (± 2.5) min (p < 0.03); 48 (60%) patients had a reduction in R from T0 to T1. In NISS 25–40 and NISS > 40 groups, changes in R value increased their significance (p = 0.04 and p < 0.03, respectively). Pathological TEG was found in 71 (88.8%) patients at T0 and 74 (92.5%) at T1. Hypercoagulation was present in 57 (71.3%) patients at T0, and in 66(82.5%) at T1. 9 (11.3%) patients had hyperfibrinolysis at T0, 7 (8.8%) patients at T1. Prevalence of StO2 < 75% at T0 was greater in patients whose TEG worsened (7 patients, 46.7%) against whose TEG remained stable or improved (8 patients, 17.4%) from T0 to T1 (p = 0.02). 48 (57.8%) patients received < 1000 mL of fluids, while 35 (42.2%) received ≥ 1000 mL. The first group had fewer patients with hypercoagulation (20, 41.6%) than the second (6, 17.6%) at T1 (p < 0.03). No differences were found for same TEG pattern at T0, nor other TEG pattern. Conclusion Our population is representative of a non-hemorrhagic severe injury subgroup. Almost all of our trauma population had coagulation abnormalities immediately after the trauma; pro-coagulant changes were the most represented regardless of the severity of injury. NISS appears to affect only R parameter on TEG. Hyperfibrinolysis has been found in a low percentage of patients. Hypoperfusion parameters do not help to identify patients with ongoing coagulation impairment. Small volume resuscitation and mild hypotermia does not affect coagulation, at least in the early post-traumatic phase. Electronic supplementary material The online version of this article (10.1007/s00068-020-01493-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alessandra Spasiano
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, ASUFC Udine, P.le Santa Maria della Misericordia 15, 33100, Udine, Italy
| | - Cristina Barbarino
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, ASUFC Udine, P.le Santa Maria della Misericordia 15, 33100, Udine, Italy
| | - Anna Marangone
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, ASUFC Udine, P.le Santa Maria della Misericordia 15, 33100, Udine, Italy.
| | - Daniele Orso
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, ASUFC Udine, P.le Santa Maria della Misericordia 15, 33100, Udine, Italy
| | - Giulio Trillò
- HEMS Division, Department of Anesthesia and Intensive Care Medicine, ASUFC Udine, 33100, Udine, Italy
| | - Roberta Giacomello
- Department of Laboratory Medicine, Institute of Clinical Pathology, University of Udine, ASUFC Udine, 33100, Udine, Italy
| | - Tiziana Bove
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, ASUFC Udine, P.le Santa Maria della Misericordia 15, 33100, Udine, Italy
| | - Giorgio Della Rocca
- Anesthesiology and Intensive Care Medicine, Department of Medicine, University of Udine, ASUFC Udine, P.le Santa Maria della Misericordia 15, 33100, Udine, Italy
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Tranexamic acid administration is associated with an increased risk of posttraumatic venous thromboembolism. J Trauma Acute Care Surg 2020; 86:20-27. [PMID: 30239375 DOI: 10.1097/ta.0000000000002061] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is used as a hemostatic adjunct for hemorrhage control in the injured patient and reduces early preventable death. However, the risk of venous thromboembolism (VTE) has been incompletely explored. Previous studies investigating the effect of TXA on VTE vary in their findings. We performed a propensity matched analysis to investigate the association between TXA and VTE following trauma, hypothesizing that TXA is an independent risk factor for VTE. METHODS This retrospective study queried trauma patients presenting to a single Level I trauma center from 2012 to 2016. Our primary outcome was composite pulmonary embolism or deep vein thrombosis. Mortality, transfusion, intensive care unit and hospital lengths of stay were secondary outcomes. Propensity matched mixed effects multivariate logistic regression was used to determine adjusted odds ratio (aOR) and 95% confidence intervals (95% CI) of TXA on outcomes of interest, adjusting for prespecified confounders. Competing risks regression assessed subdistribution hazard ratio of VTE after accounting for mortality. RESULTS Of 21,931 patients, 189 pairs were well matched across propensity score variables (standardized differences <0.2). Median Injury Severity Score was 19 (interquartile range, 12-27) and 14 (interquartile range, 8-22) in TXA and non-TXA groups, respectively (p = 0.19). Tranexamic acid was associated with more than threefold increase in the odds of VTE (aOR, 3.3; 95% CI, 1.3-9.1; p = 0.02). Tranexamic acid was not significantly associated with survival (aOR, 0.86; 95% CI, 0.23-3.25; p = 0.83). Risk of VTE remained elevated in the TXA cohort despite accounting for mortality (subdistribution hazard ratio, 2.42; 95% CI, 1.11-5.29; p = 0.03). CONCLUSION Tranexamic acid may be an independent risk factor for VTE. Future investigation is needed to identify which patients benefit most from TXA, especially given the risks of this intervention to allow a more individualized treatment approach that maximizes benefits and mitigates potential harms. LEVEL OF EVIDENCE Therapeutic, level III.
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Effect of damage control laparotomy on major abdominal complications and lengths of stay: A propensity score matching and Bayesian analysis. J Trauma Acute Care Surg 2020; 87:282-288. [PMID: 30939584 DOI: 10.1097/ta.0000000000002285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are unknown. We hypothesized that DEF would be associated with fewer abdominal complications and less resource utilization. METHODS In 2016, six US Level I trauma centers performed a yearlong, prospective, quality improvement project with the primary aim to safely decrease the use of DCL. From this cohort of patients undergoing emergent trauma laparotomy, those who underwent DCL but were judged by majority faculty vote at each center to have been candidates for potential DEF (pDEF) were prospectively identified. These pDEF patients were matched 1:1 using propensity scoring to the DEF patients. The primary outcome was the incidence of major abdominal complications (MAC). Deaths within 5 days were excluded. Outcomes were assessed using both Bayesian generalized linear modeling and negative binomial regression. RESULTS Eight hundred seventy-two total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs, 44 survived 5 days and were judged to be patients who could have safely been closed at the primary laparotomy. Thirty-nine pDEF patients were matched to 39 DEF patients. There were no differences in demographics, mechanism of injury, Injury Severity Score, prehospital/emergency department/operating room vital signs, laboratory values, resuscitation, or procedures performed during laparotomy. There was no difference in MAC between the two groups (31% DEF vs. 21% pDEF, relative risk 0.99, 95% credible interval 0.60-1.54, posterior probability 56%). Definitive laparotomy was associated with a 72%, 77%, and 72% posterior probability of more hospital-free, intensive care unit-free, and ventilator-free days, respectively. CONCLUSION In patients for whom surgeons have equipoise for DCL versus definitive surgery, definitive abdominal closure was associated with a similar probability of MAC, but a high probability of fewer hospital-free, intensive care unit-free, and ventilator-free days. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Better understanding the utilization of damage control laparotomy: A multi-institutional quality improvement project. J Trauma Acute Care Surg 2020; 87:27-34. [PMID: 31260424 DOI: 10.1097/ta.0000000000002288] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Rates of damage control laparotomy (DCL) vary widely and consensus on appropriate indications does not exist. The purposes of this multicenter quality improvement (QI) project were to decrease the use of DCL and to identify indications where consensus exists. METHODS In 2016, six US Level I trauma centers performed a yearlong, QI project utilizing a single QI tool: audit and feedback. Each emergent trauma laparotomy was prospectively reviewed. Damage control laparotomy cases were adjudicated based on the majority vote of faculty members as being appropriate or potentially, in retrospect, safe for definitive laparotomy. The rate of DCL for 2 years prior (2014 and 2015) was retrospectively collected and used as a control. To account for secular trends of DCL, interrupted time series was used to effectiveness of the QI interventions. RESULTS Eight hundred seventy-two emergent laparotomies were performed: 73% definitive laparotomies, 24% DCLs, and 3% intraoperative deaths. Of the 209 DCLs, 162 (78%) were voted appropriate, and 47 (22%) were voted to have been potentially safe for definitive laparotomy. Rates of DCL ranged from 16% to 34%. Common indications for DCL for which consensus existed were packing (103/115 [90%] appropriate) and hemodynamic instability (33/40 [83%] appropriate). The only common indication for which primary closure at the initial laparotomy could have been safely performed was avoiding a planned second look (16/32 [50%] appropriate). CONCLUSION A single faceted QI intervention failed to decrease the rate of DCL at six US Level I trauma centers. However, opportunities for improvement in safely decreasing the rate of DCL were present. Second look laparotomy appears to lack consensus as an indication for DCL and may represent a target to decrease the rate of DCL after injury. LEVEL OF EVIDENCE Epidemiological study with one negative criterion, level III.
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Draxler DF, Daglas M, Fernando A, Hanafi G, McCutcheon F, Ho H, Galle A, Gregory J, Larsson P, Keragala C, Wright DK, Tavancheh E, Au AE, Niego B, Wilson K, Plebanski M, Sashindranath M, Medcalf RL. Tranexamic acid modulates the cellular immune profile after traumatic brain injury in mice without hyperfibrinolysis. J Thromb Haemost 2019; 17:2174-2187. [PMID: 31393041 DOI: 10.1111/jth.14603] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 07/30/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is known to promote immunosuppression, making patients more susceptible to infection, yet potentially exerting protective effects by inhibiting central nervous system (CNS) reactivity. Plasmin, the effector protease of the fibrinolytic system, is now recognized for its involvement in modulating immune function. OBJECTIVE To evaluate the effects of plasmin and tranexamic acid (TXA) on the immune response in wild-type and plasminogen-deficient (plg-/- ) mice subjected to TBI. METHODS Leukocyte subsets in lymph nodes and the brain in mice post TBI were evaluated by flow cytometry and in blood with a hemocytometer. Immune responsiveness to CNS antigens was determined by Enzyme-linked Immunosorbent Spot (ELISpot) assay. Fibrinolysis was determined by thromboelastography and measuring D-dimer and plasmin-antiplasmin complex levels. RESULTS Plg-/- mice, but not plg+/+ mice displayed increases in both the number and activation of various antigen-presenting cells and T cells in the cLN 1 week post TBI. Wild-type mice treated with TXA also displayed increased cellularity of the cLN 1 week post TBI together with increases in innate and adaptive immune cells. These changes occurred despite the absence of systemic hyperfibrinolysis or coagulopathy in this model of TBI. Importantly, neither plg deficiency nor TXA treatment enhanced the autoreactivity within the CNS. CONCLUSION In the absence of systemic hyperfibrinolysis, plasmin deficiency or blockade with TXA increases migration and proliferation of conventional dendritic cells (cDCs) and various antigen-presenting cells and T cells in the draining cervical lymph node (cLN) post TBI. Tranexamic acid might also be clinically beneficial in modulating the inflammatory and immune response after TBI, but without promoting CNS autoreactivity.
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Affiliation(s)
- Dominik F Draxler
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Maria Daglas
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Anushka Fernando
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Gryselda Hanafi
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Fiona McCutcheon
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Heidi Ho
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Adam Galle
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Julia Gregory
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Pia Larsson
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Charithani Keragala
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - David K Wright
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
- The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Elnaz Tavancheh
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Amanda E Au
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Be'eri Niego
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Kirsty Wilson
- Department of Immunology and Pathology, Monash University, Melbourne, Victoria, Australia
| | - Magdalena Plebanski
- Department of Immunology and Pathology, Monash University, Melbourne, Victoria, Australia
- School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia
| | - Maithili Sashindranath
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Robert L Medcalf
- Molecular Neurotrauma and Haemostasis, Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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Zoia A, Drigo M, Piek CJ, Calcini H, Caldin M, Simioni P. Enhanced fibrinolysis detection in a natural occurring canine model with intracavitary effusions: Comparison and degree of agreement between thromboelastometry and FDPs, D-dimer and fibrinogen concentrations. PLoS One 2019; 14:e0225089. [PMID: 31725761 PMCID: PMC6855488 DOI: 10.1371/journal.pone.0225089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/29/2019] [Indexed: 12/29/2022] Open
Abstract
Dogs with intracavitary effusion have coagulative abnormalities indicative of primary fibrinolysis/hyperfibrinolysis. The aim of this case control study was to investigate by rotational thromboelastometry (ROTEM) and standard coagulation tests (fibrin-fibrinogen degradation products, D-dimer and fibrinogen) fibrinolysis in dogs with intracavitary effusions. Thirty-two dogs with intracavitary effusion and 32 control sick dogs without effusion were studied. Frequency of fibrinolysis grade of severity (i.e., hypofibrinolysis/basal fibrinolysis vs increased fibrinolysis vs hyperfibrinolysis) by ROTEM and standard coagulation tests were compared between groups. Pattern of fibrinolysis by ROTEM (i.e., late vs intermediate vs fulminant) and type of fibrinolysis by standard coagulation tests (i.e., hypofibrinolysis/basal fibrinolysis vs primary fibrinolysis vs secondary fibrinolysis vs primary hyperfibrinolysis vs secondary hyperfibrinolysis) were also compared between groups. Dogs with intracavitary effusion had a lesser degree of hypofibrinolysis and basal fibrinolysis and a higher degree of increased fibrinolysis and hyperfibrinolysis compared to controls, both by ROTEM and by standard coagulation tests (P = 0.042 and P = 0.017, respectively). Nevertheless, there was a poor agreement between the two classification schemes (34.4%, K = 0.06, 95% CI = -0.14 ‒ +0.26). Dogs with intracavitary effusion showed, by ROTEM, a lesser degree of hypofibrinolysis and basal fibrinolysis and a higher degree of late, intermediate, and fulminant fibrinolysis compared to controls (P = 0.044). Finally, dogs with intracavitary effusion had, by standard coagulation tests, a higher frequency of primary fibrinolysis and primary hyperfibrinolysis and a lower frequency of secondary fibrinolysis compared to controls. Dogs with intracavitary effusion showed an increased frequency and a different and more severe pattern of fibrinolysis compared to controls.
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Affiliation(s)
- Andrea Zoia
- Division of Internal Medicine, San Marco Veterinary Clinic, Padua, Italy
- * E-mail:
| | - Michele Drigo
- Department of Medicina Animale, Produzione e Salute, Padua University, Legnaro, Italy
| | - Christine J. Piek
- Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Helena Calcini
- Division of Internal Medicine, San Marco Veterinary Clinic, Padua, Italy
| | - Marco Caldin
- Division of Clinical Pathology, Laboratorio d’Analisi Veterinarie San Marco, Padua, Italy
| | - Paolo Simioni
- Department of Cardiologic, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
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Bosch P, Kenkre TS, Soliman D, Londino JA, Novak NE. Comparison of the Coagulation Profile of Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion With and Without Tranexamic Acid. Spine Deform 2019; 7:910-916. [PMID: 31732001 DOI: 10.1016/j.jspd.2019.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/03/2019] [Accepted: 04/16/2019] [Indexed: 11/29/2022]
Abstract
STUDY DESIGN Prospective, observational cohort study. OBJECTIVE To improve the understanding of coagulation and bleeding mechanisms during spinal deformity surgery. SUMMARY OF BACKGROUND DATA Fibrinolysis is the mechanism of bleeding for adolescent idiopathic scoliosis undergoing posterior spinal fusion. Antifibrinolytics have become popular; however, literature to support their use remains mixed. The mechanism of action has not been demonstrated. METHODS The coagulation profile of 88 adolescent idiopathic scoliosis patients undergoing posterior spinal fusion was analyzed. Standard coagulation laboratory investigations and thromboelastograms were drawn hourly through the case. Fifty-eight patients received no antifibrinolytic, whereas 30 patients received tranexamic acid by standardized protocol. The coagulation parameters, estimated blood loss, and transfusion requirements were compared in the two groups. RESULTS The two cohorts had no differences in demographic or surgical characteristics. Mean age was 13.6 years, 83% were female, a mean of 11.1 levels were fused, and the mean duration of surgery was 209 minutes. The tranexamic acid cohort did not demonstrate a decrease in blood loss. The transfusion rate, however, dropped from 47% in the non-tranexamic acid cohort to 23% in the tranexamic acid cohort (p = .03). Standard coagulation parameters did not differ between the groups. Fibrinolysis was diminished in the tranexamic acid cohort as measured by a Fibrinolysis score (mean maximum value 2.0 without tranexamic acid vs. 0.7 with tranexamic acid, p < .0001) and the lysis percent at 30 minutes by thromboelastogram (elevated to 3.9% without tranexamic acid vs. 1.2% with tranexamic acid at the 3-hour mark, p = .05). CONCLUSIONS This study provides confirmation of antifibrinolytic activity during posterior spinal fusion for adolescent idiopathic scoliosis. The presented data of fibrinolysis are proposed as standard measurements for future work on controlling blood loss during scoliosis surgery. LEVEL OF EVIDENCE Level 2, prospective comparative study.
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Affiliation(s)
- Patrick Bosch
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA.
| | - Tanya S Kenkre
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Public Health Building, 130 De Soto St, Pittsburgh, PA 15261, USA
| | - Doreen Soliman
- Department of Anesthesia, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA
| | - Joanne A Londino
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA
| | - Natalie E Novak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, 4401 Penn Avenue, Faculty Pavilion, 4th Floor, Pittsburgh, PA 15224, USA
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