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Milić D, Lazarević M, Vuković N, Kamenov A, Perić V, Golubović M, Stošić M, Spasić D, Stojiljković V, Stokanović D. Monitoring the Coagulation Profile of COVID-19 Patients Using Standard and ClotPro ® Hemostasis Tests. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1202. [PMID: 37512014 PMCID: PMC10386453 DOI: 10.3390/medicina59071202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: Coagulation disorders during COVID-19 infection are associated with a poorer prognosis and higher disease severity because thrombosis and inflammation are two processes that interfere with each other. A very important issue for clinicians is timely and adequate hemostasis and inflammation monitoring to prevent and treat potentially lethal consequences. The aim of this study was to identify specific hemostatic parameters that are associated with a higher risk of intrahospital mortality. Materials and Methods: This study was approved by the Ethics Committee of the Clinical Center Nis in Serbia. One hundred and forty-two patients presented with COVID-19 ARDS and were admitted to the ICU in the Clinic for Anesthesiology at the Clinical Center Nis from 14 April 2020 to 25 May 2020. Upon admission, blood was collected for biochemical and coagulation testing. The data obtained were analyzed using the Statistical Package for Social Sciences (SPSS v. 25, Chicago, IL, USA). Results: Among all the parameters assessed, older age; increased levels of fibrinogen, INR, D-dimer, and presepsin; and higher results in the platelet aggregation tests (aggregation induced by adenosine diphosphate based on the ADP test (AU/min), aggregation induced by arachidonic acid based on the ASPI test (AU/min), and aggregation induced by thrombin based on the TRAP test (AU/min)) and some assays of the viscoelastic test (clot amplitude after 5 min in the extrinsic coagulation pathway based on the A5 EX-test (mm), clot amplitude after 10 min in the extrinsic coagulation pathway based on the A10 EX-test (mm), clot amplitude after 5 min regarding functional fibrinogen based on the A5 FIB-test (mm), clot amplitude after 10 min regarding functional fibrinogen based on the A10 FIB-test (mm), and maximum clot firmness based on the MCF FIB-test (mm)); and lower values of viscoelastic clotting time in the extrinsic coagulation pathway based on the CT EX-test (s) were significantly correlated with mortality. In the multivariate analysis, D-dimer levels above 860 ng/mL, higher TRAP test value bins, and values above the normal reference range of the A10 FIB test were found to be independent predictors of mortality. Conclusions: Sophisticated hemostasis parameters can contribute to early risk assessment, which has initially been performed only on the basis of patients' clinical status. Hypercoagulability is the main coagulation disorder in COVID-19 infection.
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Affiliation(s)
- Dragan Milić
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Milan Lazarević
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Natalija Vuković
- Clinic for Anesthesiology and Intensive Therapy, University Clinical Center Nis, 18000 Nis, Serbia
| | - Aleksandar Kamenov
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Velimir Perić
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Mlađan Golubović
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Marija Stošić
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Dimitrije Spasić
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
| | - Vladimir Stojiljković
- Medical School of Nis, University of Nis, 18000 Nis, Serbia
- Clinic of Cardiovascular Surgery, University Clinical Center Nis, 18000 Nis, Serbia
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David JS, James A, Orion M, Selves A, Bonnet M, Glasman P, Vacheron CH, Raux M. Thromboelastometry-guided haemostatic resuscitation in severely injured patients: a propensity score-matched study. Crit Care 2023; 27:141. [PMID: 37055832 PMCID: PMC10103518 DOI: 10.1186/s13054-023-04421-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/30/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND To accelerate the diagnosis and treatment of trauma-induced coagulopathy (TIC), viscoelastic haemostatic assays (VHA) are increasingly used worldwide, although their value is still debated, with a recent randomised trial showing no improvement in outcome. The objective of this retrospective study was to compare 2 cohorts of injured patients in which TIC was managed with either a VHA-based algorithm or a conventional coagulation test (CCT)-based algorithm. METHODS Data were retrieved from 2 registries and patients were included in the study if they received at least 1 unit of red blood cell in the first 24 h after admission. A propensity score, including sex, age, blunt vs. penetrating, systolic blood pressure, GCS, ISS and head AIS, admission lactate and PTratio, tranexamic acid administration, was then constructed. Primary outcome was the proportion of subjects who were alive and free of massive transfusion (MT) at 24 h after injury. We also compared the cost for blood products and coagulation factors. RESULTS From 2012 to 2019, 7250 patients were admitted in the 2 trauma centres, and among these 624 were included in the study (CCT group: 380; VHA group: 244). After propensity score matching, 215 patients remained in each study group without any significant difference in demographics, vital signs, injury severity, or laboratory analysis. At 24 h, more patients were alive and free of MT in the VHA group (162 patients, 75%) as compared to the CCT group (112 patients, 52%; p < 0.01) and fewer patients received MT (32 patients, 15% vs. 91 patients, 42%, p < 0.01). However, no significant difference was observed for mortality at 24 h (odds ratio 0.94, 95% CI 0.59-1.51) or survival at day 28 (odds ratio 0.87, 95% CI 0.58-1.29). Overall cost of blood products and coagulation factors was dramatically reduced in the VHA group as compared to the CCT group (median [interquartile range]: 2357 euros [1108-5020] vs. 4092 euros [2510-5916], p < 0.001). CONCLUSIONS A VHA-based strategy was associated with an increase of the number of patients alive and free of MT at 24 h together with an important reduction of blood product use and associated costs. However, that did not translate into an improvement in mortality.
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Affiliation(s)
- Jean-Stéphane David
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France.
- Research on Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France.
| | - Arthur James
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Maxime Orion
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France
| | - Agathe Selves
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Mélody Bonnet
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France
| | - Pauline Glasman
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Charles-Hervé Vacheron
- Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon (HCL), Pierre Bénite Cedex, France
- Biometrics and Evolutionary Biology Laboratory, Biostatistics-Health Team, HCL, Villeurbanne, France
- Division of Public Health, Department of Biostatistics and Bioinformatics, Lyon, France
| | - Mathieu Raux
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale Et Clinique; AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Département d'Anesthésie Réanimation, Sorbonne Université, Paris, France
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Rotational thromboelastometry during Cesarean section as a predictive evaluation for the progression of persistent postpartum hemorrhage in parturients with placenta previa: A prospective observational study. Heliyon 2023; 9:e13563. [PMID: 36846658 PMCID: PMC9950826 DOI: 10.1016/j.heliyon.2023.e13563] [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: 10/23/2022] [Revised: 02/02/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023] Open
Abstract
Background The rotational thromboelastogram (ROTEM) has been used in the management of massive bleeding and transfusion strategy. This study investigated ROTEM parameters measured during Cesarean section as predictors for the progression of persistent postpartum hemorrhage (PPH) in parturients with placenta previa. Methods This prospective observational study recruited 100 women scheduled for elective Cesarean section after being diagnosed with placenta previa. Recruited women were divided into two groups according to the amount of estimated blood loss: the PPH group (PPH > 1500 ml) vs. the non-PPH group. ROTEM with laboratory tests was performed three times, preoperative, intraoperative, and postoperative time, which were compared between the two groups. Results The PPH and non-PPH groups included 57 and 41 women, respectively. The area under the receiver-operating characteristic curve of postoperative FIBTEM A5 to detect PPH was 0.76 (95% CI = 0.64 to 0.87; P < 0.001). When postoperative FIBTEM A5 was 9.5, the sensitivity and specificity were 0.74 (95% CI = 0.55 to 0.88) and 0.73 (95% CI = 0.57 to 0.86), respectively. When subgrouping the PPH group based on the postoperative FIBTEM A5 value of 9.5, intraoperative cEBL was similar between the two subgroups; however, postoperative RBC was transfused more in the subgroup with FIBTEM A5 < 9.5 than the subgroup with FIBTEM A5 ≥ 9.5 (7.4 ± 3.0 vs 5.1 ± 2.3 units, respectively; P = 0.003). Conclusion Postoperative FIBTEM A5, with appropriate selection of the cut-off value, can be a biomarker for more prolonged PPH and massive transfusion following Cesarean section by placenta previa.
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Wells M, Raja M, Rahman S. Point-of-care viscoelastic testing. BJA Educ 2022; 22:416-423. [PMID: 36304915 PMCID: PMC9596284 DOI: 10.1016/j.bjae.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 10/31/2022] Open
Affiliation(s)
- M. Wells
- Barts Health NHS Trust, London, UK
| | - M. Raja
- Royal Free London NHS Foundation Trust, London, UK
| | - S. Rahman
- Royal Free London NHS Foundation Trust, London, UK
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Is ROTEM Diagnostic in Trauma Care Associated with Lower Mortality Rates in Bleeding Patients?—A Retrospective Analysis of 7461 Patients Derived from the TraumaRegister DGU®. J Clin Med 2022; 11:jcm11206150. [PMID: 36294471 PMCID: PMC9605144 DOI: 10.3390/jcm11206150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/08/2022] [Accepted: 10/14/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction: Death from uncontrolled trauma haemorrhage and subsequent trauma-induced coagulopathy (TIC) is potentially preventable. Point-of-care devices such as rotational thromboelastometry (ROTEM®) are advocated to detect haemostatic derangements more rapidly than conventional laboratory diagnostics. Regarding reductions in RBC transfusion, the use of ROTEM has been described as being efficient and associated with positive outcomes in several studies. Objective: The effect of ROTEM use was assessed on three different outcome variables: (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality in severely injured patients. Methods and Material: A retrospective analysis of a large data set of severely injured patients collected into the TraumaRegister DGU® between 2009 and 2016 was conducted. The data of 7461 patients corresponded to the inclusion criteria and were subdivided into ROTEM-using and ROTEM-non-using groups. Both groups were analysed regarding (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality. Results: A lower mortality rate in ROTEM-using groups was observed (p = 0.043). Furthermore, more patients received haemostatic medication when ROTEM was used. In ROTEM-using groups, there was a statistically relevant higher application of massive transfusion. Conclusions: In this retrospective study, the use of ROTEM was associated with reduced mortality and an increased application of haemostatics and RBC transfusions. Prospective evidence is needed for further evidence-based recommendations.
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Malleeswaran S, Sivajothi S, Reddy MS. Viscoelastic Monitoring in Liver Transplantation. Liver Transpl 2022; 28:1090-1102. [PMID: 34724319 DOI: 10.1002/lt.26352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/21/2021] [Accepted: 10/27/2021] [Indexed: 12/13/2022]
Abstract
Cirrhosis and liver transplantation (LT) surgery are associated with substantial alterations to the patient's coagulation status. Accurate monitoring of these changes during LT can help manage bleeding proactively and potentially reduce transfusion requirements. Unlike conventional coagulation tests (CCTs), viscoelastic monitoring (VEM) can provide an accurate, real-time, point-of-care assessment of coagulation status during LT and hence has become an invaluable tool for anesthetists and intensive care physicians. However, it remains an enigmatic subject for transplantation surgeons who are more conversant with CCTs. This review discusses the principles of VEM, provides a primer to understanding and interpreting its output, and explains how it can be used to make real-world clinical decisions during LT.
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Affiliation(s)
- Selvakumar Malleeswaran
- Department of Liver Anesthesia and Critical Care, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Sivanesan Sivajothi
- Department of Liver Anesthesia and Critical Care, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Mettu Srinivas Reddy
- Department of Hepatobiliary Surgery and Liver Transplantation, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
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Is it possible to improve prediction of outcome and blood requirements in the severely injured patients by defining categories of coagulopathy? Eur J Trauma Emerg Surg 2022; 48:2751-2761. [PMID: 35118557 DOI: 10.1007/s00068-022-01882-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/17/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE It has been suggested to define the Trauma-induced coagulopathy (TIC) with a PTratio threshold of 1.20. We hypothesized that a more pragmatic classification would grade severity according to the PTratio (or corresponding ROTEM clotting time: EXTEM-CT), and that this would correlate better with the need for blood products (BP) and prognosis. METHODS Retrospective analysis of prospectively collected data of 1076 severely injured patients admitted from 01/2011 to 12/2019 in a university hospital. To determine the number of TIC categories and the best PTratio or EXTEM-CT thresholds for mortality at 24-h, a modified Mazumdar approach was used. Multivariate regression analyses were done to describe the relationship between PTratio and ROTEM parameter subclasses with mortality. RESULTS Three thresholds were, respectively, identified for PTratio (1.20, 1.90 and 3.00) and EXTEM-CT (90 s, 130 s, 200 s). The following categories were defined for PTratio: ≤ 1.20 (No TIC), 1.21-1.90 (Moderate TIC), 1.91-3.00 (severe TIC), > 3.00 (major TIC); and for EXTEM-CT: < 91 s (no TIC), 91-130 s (moderate TIC), 131-200 s (severe TIC) and > 200 s (major TIC). We observed that when the PTratio (or EXTEM-CT) increased, mortality and BP requirements increased. After multiple adjustments, we observed that each subclass of PTratio and EXTEM-CT was independently associated with mortality at 24-h. CONCLUSION In this study, we have described a pragmatic classification of coagulopathy utilizing PTratio and EXTEM-CT where increasing severity was associated with prognosis and the amount of BP administered. This could allow clinicians to better predict the outcome and anticipate the need for blood products.
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David JS, Lambert A, Taverna XJ, Incagnoli P, Geay-Baillat MO, Vassal O, Friggeri A, Inaba K. Which injured patients with moderate fibrinogen deficit need fibrinogen supplementation? Scand J Trauma Resusc Emerg Med 2021; 29:174. [PMID: 34952618 PMCID: PMC8709958 DOI: 10.1186/s13049-021-00988-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background In severely injured patients, fibrinogen supplementation is recommended when fibrinogenemia is < 1.5 g L−1, but some teams have suggested to use higher thresholds (fibrinogenemia < 2.0 g L−1 or FIBTEM clot amplitude at 5 min (A5) values < 11 mm). The goal of this study was to specify in patients with a moderate fibrinogen deficit (MFD) whether some admission characteristics would be associated with fibrinogen administration at 24 h. Methods Prospective analysis of retrospectively collected data from a trauma registry (01/2011–12/2019). MFD-C was defined by a fibrinogenemia 1.51–1.99 g L−1 or the corresponding FIBTEM-A5 values (MFD-A5) that were determined from linear regression and ROC curve analysis. Administration of fibrinogen were described according to the following admission parameters: shock index (SI) > 1, hemoglobin level < 110 g L−1 (HemoCue®), and base deficit > 5 mEq L−1. Data are expressed as count (%), median [IQR]. Results 1076 patients were included in the study and 266 (27%) had MFD-C, among them, 122/266 (46%) received fibrinogen. Patients with MFD-C who received fibrinogen were more severely injured (ISS: 27 [19–36] vs. 24 [17–29]) and had more impaired vital signs (base deficit: 5.4 [3.6–7.8] vs. 3.8 [2.0–6.0]). Linear regression analysis found a positive correlation between fibrinogen level and FIBTEM-A5 (r: 0.805). For a fibrinogen level < 1.5 g L−1 and < 2.0 g L−1, FIBTEM-A5 thresholds were 6 mm (sensitivity 85%, specificity 83%, AUC: 0.934) and 9 mm (sensitivity 84%, specificity 69%, AUC: 0.874), respectively. MFD-A5 values (185 (27%) patients) were defined as a FIBTEM-A5 between 7 and 9 mm. More than 50% of MFD-C patients presenting a SI > 1, a hemoglobin level < 110 g L−1, or a base deficit > 5.0 mEq L−1 received fibrinogen. The relative risk [95% CI] for fibrinogen administration (SI > 1) were 1.39 [1.06–1.82] for MFD-C, and 2.17 [1.48–3.19] for MFD-A5. Results were not modified after adjustment on the ISS. Conclusions We have shown in this study an association between shock parameters and fibrinogen administration. Further studies are needed to determine how these parameters may be used to guide fibrinogen administration in trauma patients with MFD.
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Affiliation(s)
- Jean-Stephane David
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France. .,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France. .,Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France. .,Service d'Anesthésie Réanimation, Centre Hospitalier Lyon Sud, 69495, Pierre Bénite cedex, France.
| | - Aline Lambert
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Xavier-Jean Taverna
- Service d'anesthésie-réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, 69008, Lyon, France
| | - Pascal Incagnoli
- Service des Urgences - SAMU, Hôpital Universitaire de Dijon, Dijon, France
| | - Marie-Odile Geay-Baillat
- Laboratoire d'Hémostase, Hôpital Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France
| | - Olivia Vassal
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Arnaud Friggeri
- Service d'anesthésie-réanimation, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, 69495, Pierre Benite, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Lyon, France
| | - Kenji Inaba
- Division of Trauma and Critical Care, Department of Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
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Qiao J, Ray B, Wians F, Abadie J. Transfusion management of trauma from the 2019 El Paso mass shooting incident. Vox Sang 2021; 117:299-312. [PMID: 34558091 DOI: 10.1111/vox.13206] [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: 05/10/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Mortality rates, transfusion ratios, trauma management logistics, and assault characteristics from the El Paso mass shooting incident (MSI) are evaluated in comparison to other MSIs. In 2019, El Paso, TX experienced the eighth-deadliest MSIs in modern US history. In this 21st mass killing in the United States of 2019, 19 people died immediately, and four of 27 injured, later died from ballistic injuries. MATERIALS AND METHODS We examined the victims' injuries, pre-hospital treatments, transfusions, rotational thromboelastometry (ROTEM) interpretation, tranexamic acid (TXA) use, and compared El Paso's outcomes with other MSIs. RESULTS Fifteen casualties were treated for bullet injuries at University Medical Center (UMC). Three were in critical condition; one died during surgery. Of the remaining victims, two were guarded, and the remaining ten in stable condition. Anatomic trauma locations included chest, abdomen, hip, breast, thigh and arm. Haemostatic agents and TXA were administered to arriving patients. Seven casualties receiving blood products were administered 95 units at UMC (45 red blood cells [RBC], 38 fresh frozen plasma [FFP], 8 platelets and 4 cryoprecipitate). ROTEM guided mass transfusion decisions in three patients. Out of seven MSIs reviewed, El Paso had the highest mortality rate (50.0%) and lowest RBC:FFP:admission ratio (1.18 at UMC). CONCLUSION We report the greatest proportion of transfusions per admission for an MSI and are first to discuss ROTEM roles to guide transfusion and manage coagulopathy during an MSI. This case highlights the severity and impact of MSIs on victims and requirements to follow established transfusion protocols with adjunct use of ROTEM, TXA and haemostatic agents.
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Affiliation(s)
- Jesse Qiao
- Department of Pathology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Bradford Ray
- Patient Blood Management and Research, University Medical Center, El Paso, TX, USA
| | - Frank Wians
- Department of Pathology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Jude Abadie
- Department of Pathology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
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Johannsen S, Brohi K, Johansson PI, Moore EE, Reinhold AK, Schöchl H, Shepherd JM, Slater B, Stensballe J, Zacharowski K, Meybohm P. Getting hit by the bus around the world - a global perspective on goal directed treatment of massive hemorrhage in trauma. Curr Opin Anaesthesiol 2021; 34:537-543. [PMID: 34074885 DOI: 10.1097/aco.0000000000001025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Major trauma remains one of the leading causes of death worldwide with traumatic brain injury and uncontrolled traumatic bleeding as the main determinants of fatal outcome. Interestingly, the therapeutic approach to trauma-associated bleeding and coagulopathy shows differences between geographic regions, that are reflected in different guidelines and protocols. RECENT FINDINGS This article summarizes main principles in coagulation diagnostics and compares different strategies for treatment of massive hemorrhage after trauma in different regions of the world. How would a bleeding trauma patient be managed if they got hit by the bus in the United States, United Kingdom, Germany, Switzerland, Austria, Denmark, Australia, or in Japan? SUMMARY There are multiple coexistent treatment standards for trauma-induced coagulopathy in different countries and different trauma centers. Most of them initially follow a protocol-based approach and subsequently focus on predefined clinical and laboratory targets.
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Affiliation(s)
- Stephan Johannsen
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ernest E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, Colorado, USA
| | - Ann-Kristin Reinhold
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - Joanna M Shepherd
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ben Slater
- Department of Anaesthesia and Acute Pain Medicine, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Jakob Stensballe
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Anesthesia and Trauma Center, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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Substitution of ROTEM FIBTEM A5 for A10 in trauma: an observational study building a case for more rapid analysis of coagulopathy. Eur J Trauma Emerg Surg 2021; 48:1077-1084. [PMID: 34136958 DOI: 10.1007/s00068-021-01652-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Rotational thromboelastometry (ROTEM®) allows guided blood product resuscitation to correct trauma-induced coagulopathy in bleeding trauma patients. FIBTEM amplitude at 10 min (A10) has been widely used to identify hypofibrinogenaemia; locally a threshold of < 11 mm has guided fibrinogen replacement. Amplitude at 5 min (A5) carries an inherent time advantage. The primary aim was to explore the relationship between FIBTEM A5 and A10 in a trauma. Secondary aim was to investigate the use of A5 as a surrogate for A10 within a fibrinogen-replacement algorithm. METHODS Retrospective observational cohort study of arrival ROTEM results from 1539 consecutive trauma patients at a Level 1 trauma centre in Australia. Consistency of agreement between FIBTEM A5 and A10 was assessed. A new fibrinogen replacement threshold was developed for A5 using the A5-A10 bias; this was clinically compared to the existing A10 threshold. RESULTS FIBTEM A5 displayed excellent consistency of agreement with A10. Intraclass correlation coefficient = 0.972 (95% confidence interval [CI] 0.969-0.974). Bias of A5 to A10 was - 1.49 (95% CI 1.43-1.56) mm. 19.34% patients met the original local threshold of A10 < 11 mm; 19.28% patients met the new, bias-adjusted threshold of A5 < 10 mm. CONCLUSION ROTEM FIBTEM A5 reliably predicts A10 in trauma. This further validates use of the A5 result over A10 allowing faster decision-making in time-critical resuscitation of trauma patients. A modification of -1 to the A10 threshold might be appropriate for use with the A5 value in trauma patients.
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Moore EE, Moore HB, Kornblith LZ, Neal MD, Hoffman M, Mutch NJ, Schöchl H, Hunt BJ, Sauaia A. Trauma-induced coagulopathy. Nat Rev Dis Primers 2021; 7:30. [PMID: 33927200 PMCID: PMC9107773 DOI: 10.1038/s41572-021-00264-3] [Citation(s) in RCA: 306] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 12/12/2022]
Abstract
Uncontrolled haemorrhage is a major preventable cause of death in patients with traumatic injury. Trauma-induced coagulopathy (TIC) describes abnormal coagulation processes that are attributable to trauma. In the early hours of TIC development, hypocoagulability is typically present, resulting in bleeding, whereas later TIC is characterized by a hypercoagulable state associated with venous thromboembolism and multiple organ failure. Several pathophysiological mechanisms underlie TIC; tissue injury and shock synergistically provoke endothelial, immune system, platelet and clotting activation, which are accentuated by the 'lethal triad' (coagulopathy, hypothermia and acidosis). Traumatic brain injury also has a distinct role in TIC. Haemostatic abnormalities include fibrinogen depletion, inadequate thrombin generation, impaired platelet function and dysregulated fibrinolysis. Laboratory diagnosis is based on coagulation abnormalities detected by conventional or viscoelastic haemostatic assays; however, it does not always match the clinical condition. Management priorities are stopping blood loss and reversing shock by restoring circulating blood volume, to prevent or reduce the risk of worsening TIC. Various blood products can be used in resuscitation; however, there is no international agreement on the optimal composition of transfusion components. Tranexamic acid is used in pre-hospital settings selectively in the USA and more widely in Europe and other locations. Survivors of TIC experience high rates of morbidity, which affects short-term and long-term quality of life and functional outcome.
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Affiliation(s)
- Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO, USA.
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA.
| | - Hunter B Moore
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Lucy Z Kornblith
- Trauma and Surgical Critical Care, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Matthew D Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Maureane Hoffman
- Duke University School of Medicine, Transfusion Service, Durham VA Medical Center, Durham, NC, USA
| | - Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg and Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | | | - Angela Sauaia
- Department of Surgery, University of Colorado Denver, Aurora, CO, USA
- Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
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Sribnick EA, Wenger N, Nicol K, Tobias JD. Use of viscoelastic monitoring and prothrombin complex concentrate in a paediatric patient with polytrauma and severe traumatic brain injury. BMJ Case Rep 2020; 13:13/12/e236608. [PMID: 33318272 PMCID: PMC7737072 DOI: 10.1136/bcr-2020-236608] [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: 12/15/2022] Open
Abstract
Viscoelastic monitoring (VEM) tools, such as rotational thrombelastometry, have been used extensively to measure coagulopathy in adults but have received less attention in paediatric care. The presented case involves a 5-year-old boy who was brought to the emergency department after a motor vehicle collision with a Glasgow Coma Scale score of 6T and extensive injuries, including a subdural hematoma. VEM was used to monitor the patient's coagulopathy and to inform treatment measures by allowing real-time visualisation of the patient's coagulation status. VEM was additionally used to direct blood product replacement in preparation for neurosurgical intervention, and 4-factor prothrombin complex concentrate (PCC) was used to help reverse the coagulopathy. The patient underwent successful hemicraniectomy after improvement of his coagulopathy. In paediatrics, VEM and PCC are increasingly being used for post-trauma coagulopathy, and this case highlights their potential promise and the need for further research.
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Affiliation(s)
- Eric A Sribnick
- Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio, USA,Deparmtent of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Nicole Wenger
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kathleen Nicol
- Deaprtment of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA,Department of Pathology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA,Depatment of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Scala E, Marcucci C. Massive Hemorrhage: The Role of Whole Blood Viscoelastic Assays. Hamostaseologie 2020; 40:515-523. [PMID: 33091949 DOI: 10.1055/a-1227-8050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Viscoelastic whole blood tests are increasingly used to guide hemostatic therapy in bleeding patients in the perioperative, trauma, and obstetric settings. Compared with standard laboratory tests of hemostasis, they have a shorter turnaround time and provide simultaneous information on various aspects of clot formation and lysis. The two available brands TEG (thromboelastography) and ROTEM (rotational thromboelastometry) provide devices that are either manually operated or fully automated. The automation allows for the assays to be used as point-of-care tests increasing their usefulness in massively bleeding patients with rapidly changing hemostatic profiles. While the number of research papers on the subject and the number of published treatment algorithms increase rapidly, the influence of the use of these devices on patient outcome needs yet to be established. In this article, we first review the technology of these devices and the parameters provided by the assays. Next, we present the problems encountered when choosing cut-off values that trigger intervention. Furthermore, we discuss the studies examining their influence on clinical outcomes, and finally, we briefly highlight some of the most important limitations and pitfalls inherent to these assays.
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Affiliation(s)
- Emmanuelle Scala
- Department of Anesthesiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Carlo Marcucci
- Department of Anesthesiology, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Spagnolello O, J Reed M, Dauncey S, Timony-Nolan E, Innes C, Allen JMM, Williams MJ, Church N, Dunn MJG, Blackstock C, Nimmo AF. Introduction of a ROTEM protocol for the management of trauma-induced coagulopathy. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620957919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Aims Point-of-care viscoelastic tests such as rotational thrombelastometry (ROTEM) and thromboelastography (TEG) give rapid information on the kinetics of clot formation, clot strength and fibrinolysis. We developed a ROTEM algorithm for the management of trauma patients at risk of massive haemorrhage using either 5 or 10 minute EXTEM and FIBTEM ROTEM thresholds. Study aims were (a) to compare time to results for ROTEM testing versus laboratory conventional coagulation testing (CCT) and (b) to compare incidence of Trauma-induced coagulopathy (TIC) for our 5 and 10 minute ROTEM algorithms versus both the CCT-based European guideline algorithm and the ROTEM-based iTACTIC study algorithm, in both MT and non-MT patients. Methods Single centre, prospective, observational Emergency Department based study. All trauma patients who underwent ROTEM testing were included. Data was collected from the ROTEM Sigma machine and hospital Electronic Patient Records and analysed. Results Between April 2016 and May 2019, 57 trauma patients were enrolled. Mean age was 47.4 years (SD 19.4) and 44 patients (77.2%) were male. Eleven patients (19.3%) required massive transfusion (MT), 5 patients died in ED (8.8%) and overall in-hospital mortality was 22.8% (n = 13). Median time from admission to CCT result was 83 minutes (IQR 60–93) compared to 51 minutes (IQR 32-93; p = 0.0006) for ROTEM A5 results. This time difference was present for both MT and non-MT patients. Trauma-induced coagulopathy (TIC) was identified in 14 (24.5%) patients using CCT compared to 22 (38.5%) using ROTEM (p = 0.11 ns). Conclusion Our ROTEM Sigma based algorithm enables a coagulation result to be obtained faster than laboratory CCT and could lead to earlier clinical intervention.
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Affiliation(s)
- Ornella Spagnolello
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Steve Dauncey
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Emer Timony-Nolan
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Catherine Innes
- SNBTS Transfusion Team, Scottish National Blood Transfusion Service, Edinburgh, UK
| | - Jennifer MM Allen
- SNBTS Transfusion Team, Scottish National Blood Transfusion Service, Edinburgh, UK
| | - Michael J Williams
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Nick Church
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Mark JG Dunn
- Department of Critical Care, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Caroline Blackstock
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair F Nimmo
- Department of Anaesthetics, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
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Sahli SD, Rössler J, Tscholl DW, Studt JD, Spahn DR, Kaserer A. Point-of-Care Diagnostics in Coagulation Management. SENSORS (BASEL, SWITZERLAND) 2020; 20:E4254. [PMID: 32751629 PMCID: PMC7435714 DOI: 10.3390/s20154254] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/17/2020] [Accepted: 07/28/2020] [Indexed: 12/15/2022]
Abstract
This review provides a comprehensive and up-to-date overview of point-of-care (POC) devices most commonly used for coagulation analyses in the acute settings. Fast and reliable assessment of hemostasis is essential for the management of trauma and other bleeding patients. Routine coagulation assays are not designed to visualize the process of clot formation, and their results are obtained only after 30-90 m due to the requirements of sample preparation and the analytical process. POC devices such as viscoelastic coagulation tests, platelet function tests, blood gas analysis and other coagulometers provide new options for the assessment of hemostasis, and are important tools for an individualized, goal-directed, and factor-based substitution therapy. We give a detailed overview of the related tests, their characteristics and clinical implications. This review emphasizes the evident advantages of the speed and predictive power of POC clot measurement in the context of a goal-directed and algorithm-based therapy to improve the patient's outcome. Interpretation of viscoelastic tests is facilitated by a new visualization technology.
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Affiliation(s)
- Sebastian D. Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - David W. Tscholl
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Jan-Dirk Studt
- Division of Hematology, University and University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, 8091 Zurich, Switzerland; (S.D.S.); (J.R.); (D.W.T.); (D.R.S.)
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Abstract
Two of the most commonly used viscoelastic hemostatic assays, thromboelastometry (ROTEM) and thrombelastography (TEG), have proven to decrease allogenic blood transfusions with cost reduction and possibly decrease mortality and morbidity in cardiac, trauma, and other bleeding patients. This article compares the two devices to provide guidance on the selection and use of these monitoring systems. Their second-generation assays, TEG 6S and ROTEM Sigma, are also discussed.
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Affiliation(s)
- Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA -
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Thanasrisuebwong P, Surarit R, Bencharit S, Ruangsawasdi N. Influence of Fractionation Methods on Physical and Biological Properties of Injectable Platelet-Rich Fibrin: An Exploratory Study. Int J Mol Sci 2019; 20:ijms20071657. [PMID: 30987117 PMCID: PMC6479392 DOI: 10.3390/ijms20071657] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/19/2019] [Accepted: 03/30/2019] [Indexed: 12/13/2022] Open
Abstract
Injectable platelet-rich fibrin (i-PRF) has been used as an autografting material to enhance bone regeneration through intrinsic growth factors. However, fractionation protocols used to prepare i-PRF can be varied and the effects of different fractionation protocols are not known. In this study, we investigated the influence of different fractions of i-PRF on the physical and biological properties derived from variations in i-PRF fractionation preparation. The i-PRF samples, obtained from the blood samples of 10 donors, were used to harvest i-PRF and were fractioned into two types. The yellow i-PRF fractionation was harvested from the upper yellow zone, while the red i-PRF fractionation was collected from both the yellow and red zone of the buffy coat. The viscoelastic property measurements, including the clot formation time, α-angle, and maximum clot firmness, were performed by rotational thromboelastometry. The fibrin network was examined using a scanning electron microscope. Furthermore, the concentration of growth factors released, including VEGF, TGF-β1, and PDGF, were quantified using ELISA. A paired t-test with a 95% confidence interval was used. All three viscoelastic properties were statistically significantly higher in the yellow i-PRF compared to the red i-PRF. The scanning electron microscope reviewed more cellular components in the red i-PRF compared to the yellow i-PRF. In addition, the fibrin network of the yellow i-PRF showed a higher density than that in the red i-PRF. There was no statistically significant difference between the concentration of VEGF and TGF-β1. However, at Day 7 and Day 14 PDGF concentrations were statistically significantly higher in the red i-PRF compared to the yellow group. In conclusion, these results showed that the red i-PRF provided better biological properties through the release of growth factors. On the other hand, the yellow i-PRF had greater viscoelastic physical properties. Further investigations into the appropriate i-PRF fractionation for certain surgical procedures are therefore necessary to clarify the suitability for each fraction for different types of regenerative therapy.
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Affiliation(s)
- Prakan Thanasrisuebwong
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok 10400, Thailand.
- Ph.D. program in Oral Biology, Faculty of Dentistry, Mahidol University, Bangkok 10400, Thailand.
| | - Rudee Surarit
- Department of Oral Biology, Faculty of Dentistry, Mahidol University, Bangkok 10400, Thailand.
| | - Sompop Bencharit
- Department of General Dentistry, School of Dentistry, Virginia Commonwealth University, Richmond, VA 23298, USA.
- Department of Biomedical Engineering, College of Engineering, Virginia Commonwealth University, Richmond, VA 23298, USA.
| | - Nisarat Ruangsawasdi
- Department of Pharmacology, Faculty of Dentistry, Mahidol University, Bangkok 10400, Thailand.
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Charlesworth M, Arya R. Direct oral anticoagulants: peri-operative considerations and controversies. Anaesthesia 2018; 73:1460-1463. [DOI: 10.1111/anae.14455] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- M. Charlesworth
- Department of Cardiothoracic Anaesthesia; Wythenshawe Hospital; Manchester University Hospitals NHS Foundation Trust; Manchester UK
| | - R. Arya
- Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
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