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Lorentsson HJN, Clausen CR, Faurholt-Jepsen D, Hansen KB, Jensen SG, Krogh-Madsen R, Hagelqvist PG, Johansson PI, Vilsbøll T, Knop FK, Ravn P. The effect of Mycobacterium tuberculosis treatment on thrombelastography-assessed haemostasis: a prospective cohort study. Thromb J 2024; 22:54. [PMID: 38918780 PMCID: PMC11201340 DOI: 10.1186/s12959-024-00625-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/19/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Tuberculosis disease (TB) and tuberculosis infection (TBI) have been associated with increased risk of cardiovascular disease which may be connected to infection-related haemostatic changes. It is unknown if treatment of Mycobacterium tuberculosis influences haemostasis. Here, we assessed if TB or TBI treatment affects thrombelastography (TEG)-assessed haemostasis. METHODS Individuals with TB or TBI were included from a TB outpatient clinic in Copenhagen, Denmark. Patients treated with antithrombotic medication or systemic immunosuppressants were excluded. TEG analysis was performed before and after TB/TBI treatment using the TEG®6s analyser to provide data on the reaction time of clot initiation (R) (min), the speed of clot formation (K) (min) and clot build-up (Angle) (°), maximum clot strength (MA) (mm), and clot breakdown/fibrinolysis (LY30) (%). Differences in TEG were assessed using paired t tests. RESULTS We included eleven individuals with TB with median [interquartile range] [IQR] age 52 (Liu et al. in Medicine (United States) 95, 2016) years and mean (standard deviation) (SD) body mass index (BMI) 24.7 (6.3) kg/m2 as well as 15 individuals with TBI with median [IQR] age 49 (Wells et al. in Am J Respir Crit Care Med 204:583, 2021) years and BMI 26.0 (3.2) kg/m2. Treatment reduced MA for both TB (64.0 (6.3) vs. 57.9 (5.2) mm, p = 0.016) and TBI (61.3 (4.1) vs. 58.6 (5.0) mm, p = 0.023) whereas R, K, Angle and LY30 were unaffected. CONCLUSION TEG analysis showed that treatments of TB and TBI were associated with reduced MA which may indicate the existence of cardiovascular benefits from therapy. TRIAL REGISTRATION Registered at ClinicalTrials.gov 05 April 2021 with registration number NCT04830462.
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Affiliation(s)
- Hans Johan Niklas Lorentsson
- Section of Infectious Diseases, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark.
- Section of Infectious Diseases, Department of Medicine, Herlev and Gentofte Hospital, Hellerup Hospitalsvej 1, +45 38 67 38 67, Hellerup, 2900, Denmark.
| | - Christina R Clausen
- Section of Infectious Diseases, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Daniel Faurholt-Jepsen
- Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Sidse Graff Jensen
- Section of Respiratory Diseases, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Rikke Krogh-Madsen
- Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
- Center for Physical Activity Research, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Per G Hagelqvist
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Pär I Johansson
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- CAG Center for Endotheliomics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Tina Vilsbøll
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Filip K Knop
- Center for Clinical Metabolic Research, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Pernille Ravn
- Section of Infectious Diseases, Department of Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Wang J, Ho P, Nandurkar H, Lim HY. Overall haemostatic potential assay for prediction of outcomes in venous and arterial thrombosis and thrombo-inflammatory diseases. J Thromb Thrombolysis 2024; 57:852-864. [PMID: 38649560 DOI: 10.1007/s11239-024-02975-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 04/25/2024]
Abstract
Thromboembolic diseases including arterial and venous thrombosis are common causes of morbidity and mortality globally. Thrombosis frequently recurs and can also complicate many inflammatory conditions through the process of 'thrombo-inflammation,' as evidenced during the COVID-19 pandemic. Current candidate biomarkers for thrombosis prediction, such as D-dimer, have poor predictive efficacy. This limits our capacity to tailor anticoagulation duration individually and may expose lower risk individuals to undue bleeding risk. Global coagulation assays, such as the Overall Haemostatic Potential (OHP) assay, that investigate fibrin generation and fibrinolysis, may provide a more accurate and functional assessment of hypercoagulability. We present a review of fibrin's critical role as a central modulator of thrombotic risk. The results of our studies demonstrating the OHP assay as a predictive biomarker in venous thromboembolism, chronic renal disease, diabetes mellitus, post-thrombotic syndrome, and COVID-19 are discussed. As a comprehensive and global measurement of fibrin generation and fibrinolytic capacity, the OHP assay may be a valuable addition to future multi-modal predictive tools in thrombosis.
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Affiliation(s)
- Julie Wang
- Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia.
| | - Prahlad Ho
- Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
| | - Harshal Nandurkar
- Australian Centre for Blood Diseases, Monash Health, Melbourne, Australia
| | - Hui Yin Lim
- Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
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Wilson S, Joseph J, Danta M, Rabbolini DJ. Viscoelastometry to Manage Bleeding in Liver Disease. Cureus 2023; 15:e41401. [PMID: 37546051 PMCID: PMC10402654 DOI: 10.7759/cureus.41401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
A state of "re-balanced haemostasis" describes complex coagulation changes that arise in patients with liver disease. Changes include alterations in procoagulant and anticoagulant proteins, platelets and von Willebrand factor, as well as the fibrinolytic system. Various circumstances including infection, trauma, or surgery may disrupt this balance and predispose an individual to bleeding or thrombosis. The prothrombin time, international normalised ratio, and activated partial thromboplastin time are conventional coagulation screening tests that are routinely employed by clinicians to investigate unexplained bleeding, monitor anticoagulation, and inform preoperative assessments of bleeding risk. These standard coagulation tests assess quantitative defects in procoagulant clotting factors and are insensitive to levels of natural anticoagulants, which together with procoagulant factors, are often perturbed in liver disease. Therefore, the prolongation of clotting times measured by these tests often does not reflect the multifaceted alterations of haemostasis in these patients. Viscoelastic testing (VET) provides a more encompassing assessment of clotting function by recording real-time viscoelastic changes in whole blood and includes parameters that provide information on coagulation factor function, platelet contribution to clot formation, as well as fibrinolysis. To date, VET has been employed to predict and inform transfusion support in obstetric, trauma, and cardiac surgical fields, and its use in patients undergoing liver transplantation is well established. The ability of VET to accurately predict bleeding risk and precisely guide transfusion algorithms for patients with liver disease undergoing other invasive procedures or experiencing bleeding complications has been the topic of research over the last decade. This review is a critical summary of this data and provides a detailed snapshot of the position of VET as a clinical tool in patients with liver disease.
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Affiliation(s)
- Samantha Wilson
- Gastroenterology and Hepatology, School of Clinical Medicine, St. Vincent's Healthcare Campus, Faculty of Medicine, University of New South Wales, Sydney, AUS
| | - Joanne Joseph
- Hematology, School of Clinical Medicine, St. Vincent's Healthcare Campus, Faculty of Medicine, University of New South Wales, Sydney, AUS
- Hematology, St. Vincent's Centre for Applied Medical Research, St Vincent's Hospital, Sydney, AUS
| | - Mark Danta
- Gastroenterology and Hepatology, School of Clinical Medicine, St. Vincent's Healthcare Campus, Faculty of Medicine, University of New South Wales, Sydney, AUS
- Gastroenterology and Hepatology, St. Vincent's Hospital, Sydney, AUS
| | - David J Rabbolini
- Faculty of Medicine and Health, University of Sydney, Sydney, AUS
- Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
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Gurunathan U, Chiang L, Hines J, Pearse B, McKenzie S, Hay K, Mullany D, Nandurkar H, Eley V. Association Between Thromboelastometry Identified Hypercoagulability and Thromboembolic Complications After Arthroplasty: A Prospective Observational Study in Patients With Obesity. Clin Appl Thromb Hemost 2023; 29:10760296231199737. [PMID: 37814542 PMCID: PMC10566273 DOI: 10.1177/10760296231199737] [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: 06/24/2023] [Revised: 08/09/2023] [Accepted: 08/22/2023] [Indexed: 10/11/2023] Open
Abstract
The prothrombotic state of obesity can increase the risk of thromboembolism. We aimed to investigate if there was an association between baseline hypercoagulable rotational thromboelastometry (ROTEM) profile and thromboembolic complications in arthroplasty patients with obesity. Patients with a body mass index ≥ 25 kg/m2 and/or waist circumference ≥94 cm (M) and 80 cm (F) undergoing hip and knee arthroplasty had pre- and postoperative ROTEM. ROTEM values were compared by outcome status using an independent sample equal-variance t-test. Of the 303 total participants, hypercoagulability defined as extrinsically activated thromboelastometry maximum clot firmness G score ≥ 11 K dyne/cm2, was observed in 90 (30%) of the 300 participants with preoperative ROTEM assays. Clinically significant thromboembolic complications occurred in 5 (1.7%) study participants before discharge and in 10 (3.3%) by 90 days. These included 6 with pulmonary emboli, 3 with deep venous thrombus, and 1 with myocardial infarction. We found no evidence for an association between baseline hypercoagulability and incident thromboembolic events, analysis limited by the number of events. Postoperative decrease in platelets and an increase in fibrinogen were observed. ROTEM parameter changes differed across obesity categories.
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Affiliation(s)
- Usha Gurunathan
- Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Lily Chiang
- Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Joel Hines
- Adult Intensive Care Unit, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Bronwyn Pearse
- Blood Management Unit, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Scott McKenzie
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Karen Hay
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Daniel Mullany
- Department of Anaesthesia and Perfusion Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Harshal Nandurkar
- Department of Haematology, Alfred Health, Melbourne, VIC, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Victoria Eley
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
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EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
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Fan D, Ouyang Z, Ying Y, Huang S, Tao P, Pan X, Lu S, Pan Q. Thromboelastography for the Prevention of Perioperative Venous Thromboembolism in Orthopedics. Clin Appl Thromb Hemost 2022; 28:10760296221077975. [PMID: 35379018 PMCID: PMC8988665 DOI: 10.1177/10760296221077975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We have reviewed a large number of relevant literature to determine the deficiencies of orthopedics in the diagnosis and prevention of venous thromboembolism(VTE)events during the perioperative period, and found that the TEG technology has been widely used after liver transplantation, which may make up for the deficiencies. This review expounds the detection principle and latest thromboelastography (TEG) development, and highlights the advantages of TEG over previous screening methods in diagnosing hypercoagulability. By analyzing the correlation and consistency between TEG and conventional coagulation test, reliable indexes for diagnosing hypercoagulability and important parameters for guiding perioperative anticoagulation treatment were summarized. Furthermore, our work contributes to further studies of TEG in orthopedics. Based on the research results, we believe that TEG may help orthopedists to identify and predict VTE events, use anticoagulants, eventually reduce the occurrence of VTE events.
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Affiliation(s)
- Dejing Fan
- The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ziyao Ouyang
- The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yanping Ying
- The First Affiliated Hospital of Guangxi Medical University
| | | | - Pinyue Tao
- The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiao Pan
- The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Shuyu Lu
- The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Qini Pan
- The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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Milczak A, Winiarczyk D, Winiarczyk S, Bochyńska D, Adaszek Ł, Winiarczyk M, Lechowski R. Procoagulant and anticoagulant plasma indicators in diabetic dogs showing increased antithrombin III levels in canine diabetes mellitus. BMC Vet Res 2022; 18:108. [PMID: 35305618 PMCID: PMC8933892 DOI: 10.1186/s12917-022-03179-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 02/07/2022] [Indexed: 11/19/2022] Open
Abstract
Background Diabetes mellitus (DM) often leads to dangerous thromboembolic complications in humans. DM is also a relatively common endocrinopathy of dogs. There is scarce information regarding procoagulant and anticoagulant plasma indicators in this disease. The aim of the study was to evaluate the levels of the selected plasma haemostatic parameters in dogs suffering from diabetes. The study group consisted of 20 dogs meeting all the inclusion criteria, with fasting glycaemia exceeding 11.1 mmol/l. The control group consisted of 15 healthy dogs presented for routine examination. An evaluation of the prothrombin time (PT); and fibrinogen, D-dimer and antithrombin III (ATIII) levels was performed. Results Except for ATIII activity, the haemostatic parameter differences were not statistically significant. High values of ATIII activity were observed in 90% of diabetic dogs. On average, the values amounted to 166.6% and were 31.4% higher than those in the control group. The ATIII activity in the diabetic group was significantly higher than that in the control group (p = 0.0004). Conclusions Here, we report elevated levels of ATIII in diabetic dogs. This finding may suggest the protective role of ATIII against potential thrombotic events. However, the exact role of ATIII in dog diabetes remains unclear.
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8
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Hoek M, Schultz M, Alummoottil S, Aneck-Hahn N, Mathabe K, Bester J. Ex vivo Vitamin D supplementation improves viscoelastic profiles in prostate cancer patients. Clin Hemorheol Microcirc 2022; 81:221-232. [DOI: 10.3233/ch-211353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Increased risk of thromboembolic events is associated with prostate cancer, specifically linked to activation of tissue factor. Vitamin D has potential anticoagulant effects by the downregulation of tissue factor expression. OBJECTIVES: To evaluate the effects on clot formation, the morphological and viscoelastic profiles of prostate cancer patients, before and after ex vivo supplementation of Vitamin D was studied. METHODS: Participants were recruited into a metastatic, non-metastatic and reference group. Whole blood samples were treated ex vivo with a dose of 0.5μg/kg Calcitriol. Clot kinetics were assessed using Thromboelastography ®. Morphology of the blood components were studied using scanning electron microscopy (SEM). RESULTS: Results from the Thromboelastography ® and SEM indicated no major differences between the non-metastatic group before and after treatment compared to the reference group. The Thromboelastography ® showed that the metastatic group had an increased viscoelastic profile relating to a hypercoagulable state. Visible changes with regards to platelet activation and fibrin morphology were demonstrated with SEM analysis of the metastatic group. The viscoelastic and morphological properties for the non-metastatic group after treatment improved to be comparable to the reference group. CONCLUSION: Vitamin D supplementation may lead to a more favorable viscoelastic profile, with less dangerous clots forming.
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Affiliation(s)
- Marinka Hoek
- Department of Urology, University of Pretoria, Pretoria, South Africa
| | - Michelle Schultz
- Department of Physiology, University of Pretoria, Pretoria, South Africa
| | - Sajee Alummoottil
- Department of Physiology, University of Pretoria, Pretoria, South Africa
| | - Natalie Aneck-Hahn
- Department of Urology, University of Pretoria, Pretoria, South Africa
- Environmental Chemical Pollution and Health Research Unit, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Kgomotso Mathabe
- Department of Urology, University of Pretoria, Pretoria, South Africa
| | - Janette Bester
- Department of Physiology, University of Pretoria, Pretoria, South Africa
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Fattorutto M, Bouckaert Y, Brauner J, Franck S, Bouton F, Heuse D, Bouckaert C, Bruyneel A. Pragmatic study of a thromboprophylaxis algorithm in critically ill patients with SARS-COV-2 infection. J Thromb Thrombolysis 2022; 53:58-66. [PMID: 34173169 PMCID: PMC8233177 DOI: 10.1007/s11239-021-02514-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 01/08/2023]
Abstract
The optimal thromboprophylactic strategy for patients affected by Coronavirus disease 2019 (COVID-19) has been debated among experts. This study evaluated the safety and efficacy of a thromboprophylaxis algorithm. This was a retrospective, single-center study in critically ill patients admitted to the intensive care unit (University affiliated Hospital) for acute respiratory failure due to Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2). From March 16 to April 9, 2020, thromboprophylaxis was adjusted according to weight (control group, n = 19) and after this date, thromboprophylaxis depended on an algorithm based on thrombotic and hemorrhagic risk factors (protocol group, n = 13). With regard to safety (number of major bleeding events and blood transfusions), the groups were not significantly different. With regard to efficacy, the number of thrombotic events decreased from 37 to 0%, p = 0.025 after implementation of the algorithm. Also, peak fibrinogen dropped from 8.6 (7.2-9.3) to 6.5 (4.6-8.4) g/L, p = 0.041 and D-dimers from 2194 (1464-3763) to 1486 (900-2582) ng/mL, p = 0.0001. In addition, length of stay declined from 19 (10-31) to 5 (3-19) days, p = 0.009. In conclusion, a tailored thromboprophylaxis algorithm (risk stratification based on clinical parameters and biological markers) reduce thrombotic phenomena in critically ill COVID-19 patients without increasing major bleeding.
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Affiliation(s)
- Maurizio Fattorutto
- Department of Anesthesiology, Centre Hospitalier Universitaire Tivoli, Avenue Max Buset 34, 7100, La Louvière, Belgium.
| | - Yves Bouckaert
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Jonathan Brauner
- Department of Clinical Biology/Blood Bank, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Stéphane Franck
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Fabrice Bouton
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | - Danielle Heuse
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
| | | | - Arnaud Bruyneel
- Intensive Care Unit, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
- School of Public Health, Université Libre Bruxelles, Brussels, Belgium
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Neethling C, Calligaro G, Miller M, Opie JJS. The evolution of clot strength in critically-ill COVID-19 patients: a prospective observational thromboelastography study. Thromb J 2021; 19:83. [PMID: 34742307 PMCID: PMC8572064 DOI: 10.1186/s12959-021-00331-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/14/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Few studies detail the evolution of COVID-19 associated coagulopathy. We performed serial thromboelastography (TEG) and laboratory coagulation studies in 40 critically-ill, mechanically ventilated COVID-19 patients over a 14-day period and analysed differences between 30-day survivors and non-survivors. METHODS Single-center prospective, observational study including 40 patients with severe COVID-19 pneumonia admitted to the intensive care unit (ICU) for mechanical ventilation. TEG analysis was performed on days 1, 7 and 14 of ICU admission and laboratory coagulation studies were performed on days 1 and 14. Coagulation variables were evaluated for change over the 14-day observation period. Differences between survivors and non-survivors at 30-days were analysed and compared. RESULTS On admission, TEG maximum amplitude (MA) with heparinase correction was above the upper limit of the reference range in 32 (80%) patients while 33 (82.5%) presented with absent clot lysis at 30 min. The functional fibrinogen MA was also elevated above the upper limit of the reference range in 37 (92.5%) patients. All patients had elevated D-dimer and fibrinogen levels, mildly prolonged prothrombin times (PT), normal platelet counts and normal activated partial thromboplastin times (aPTT). The heparinase MA decreased significantly with time and normalised after 14 days (p = < 0.001) while the increased fibrin contribution to clot strength persisted with time (p = 0.113). No significant differences in TEG analysis were noted between 30-day survivors and non-survivors at all time points. No patients developed disseminated intravascular coagulopathy (DIC) after 14-days, however thrombosis and bleeding were each reported in 3 (7.5%) patients. CONCLUSION Critically-ill patients with COVID-19 present in a hypercoagulable state characterised by an increased clot strength. This state normalises after 14 days despite a persistently increased fibrin contribution to clot strength. We were unable to demonstrate any significant differences in TEG parameters between 30-day survivors and non-survivors at all time points.
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Affiliation(s)
- Colette Neethling
- Department of Anaesthesia & Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, Anzio Drive, Observatory, Cape Town, 7925, South Africa.
| | - Gregory Calligaro
- Division of Pulmonology, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Malcolm Miller
- Department of Anaesthesia & Perioperative Medicine, University of Cape Town, Groote Schuur Hospital, Anzio Drive, Observatory, Cape Town, 7925, South Africa
| | - Jessica J S Opie
- Division of Haematology, Department of Pathology, University of Cape Town & National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
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Lloyd-Donald P, Lee WS, Liu GM, Bellomo R, McNicol L, Weinberg L. Thromboelastography in elective total hip arthroplasty. World J Orthop 2021; 12:555-564. [PMID: 34485102 PMCID: PMC8384610 DOI: 10.5312/wjo.v12.i8.555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/21/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hypercoagulability plays an important role in predisposing patients to venous thromboembolism (VTE) after total hip arthroplasty (THA). We used thromboelastography (TEG) to examine the coagulation status of patients undergoing THA.
AIM To examine coagulation as measured by TEG in patients undergoing THA who received standard VTE chemoprophylaxis with enoxaparin.
METHODS After ethical approval, we performed a retrospective analysis of data collected in patients undergoing primary elective THA. We analyzed TEG data on samples performed before skin incision, intraoperatively and for 5 d postoperatively. Conventional coagulation tests were performed preoperatively and on postoperative day 5.
RESULTS Twenty patients undergoing general anesthesia and 32 patients undergoing spinal anesthesia (SA) were included. TEG demonstrated a progressively hypercoagulable state postoperatively, characterized by elevated maximum amplitude. TEG also demonstrated transient intraoperative hypercoagulability in patients receiving SA. In contrast, conventional coagulation tests were normal in all patients, pre- and postoperatively, except for an increase in plasma fibrinogen day 5 postoperatively.
CONCLUSION Despite VTE prophylaxis, patients following total hip replacement remain in a hypercoagulable state as measured by both TEG and conventional tests. This group may benefit from more optimal anticoagulation and/or additional perioperative hemostatic monitoring, via TEG or otherwise.
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Affiliation(s)
| | - Wen-Shen Lee
- Department of Anesthesia, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Guo-Ming Liu
- Department of Anesthesia, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne 3084, Victoria, Australia
| | - Larry McNicol
- Department of Anesthesia, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Laurence Weinberg
- Department of Anesthesia, Austin Health, Heidelberg 3084, Victoria, Australia
- Department of Surgery, The University of Melbourne, Austin Health, Melbourne 3084, Victoria, Australia
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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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13
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Bareille M, Hardy M, Douxfils J, Roullet S, Lasne D, Levy JH, Stépanian A, Susen S, Frère C, Lecompte T, Mullier F. Viscoelastometric Testing to Assess Hemostasis of COVID-19: A Systematic Review. J Clin Med 2021; 10:jcm10081740. [PMID: 33923851 PMCID: PMC8072929 DOI: 10.3390/jcm10081740] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 02/06/2023] Open
Abstract
Infection by SARS-CoV-2 is associated with a high risk of thrombosis. The laboratory documentation of hypercoagulability and impaired fibrinolysis remains a challenge. Our aim was to assess the potential usefulness of viscoelastometric testing (VET) to predict thrombotic events in COVID-19 patients according to the literature. We also (i) analyzed the impact of anticoagulation and the methods used to neutralize heparin, (ii) analyzed whether maximal clot mechanical strength brings more information than Clauss fibrinogen, and (iii) critically scrutinized the diagnosis of hypofibrinolysis. We performed a systematic search in PubMed and Scopus databases until 31st December 2020. VET methods and parameters, and patients' features and outcomes were extracted. VET was performed for 1063 patients (893 intensive care unit (ICU) and 170 non-ICU, 44 studies). There was extensive heterogeneity concerning study design, VET device used (ROTEM, TEG, Quantra and ClotPro) and reagents (with non-systematic use of heparin neutralization), timing of assay, and definition of hypercoagulable state. Notably, only 4 out of 25 studies using ROTEM reported data with heparinase (HEPTEM). The common findings were increased clot mechanical strength mainly due to excessive fibrinogen component and impaired to absent fibrinolysis, more conspicuous in the presence of an added plasminogen activator. Only 4 studies out of the 16 that addressed the point found an association of VETs with thrombotic events. So-called functional fibrinogen assessed by VETs showed a variable correlation with Clauss fibrinogen. Abnormal VET pattern, often evidenced despite standard prophylactic anticoagulation, tended to normalize after increased dosing. VET studies reported heterogeneity, and small sample sizes do not support an association between the poorly defined prothrombotic phenotype of COVID-19 and thrombotic events.
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Affiliation(s)
- Marion Bareille
- Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
- Correspondence:
| | - Michaël Hardy
- Service D’anesthésiologie, CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC), Département de Pharmacie, Université de Namur, 5000 Namur, Belgium;
- Qualiblood S.A., 5000 Namur, Belgium
| | - Stéphanie Roullet
- CHU Bordeaux, Service D’Anesthésie-Réanimation Tripode, 33000 Bordeaux, France;
- Biologie des Maladies Cardiovasculaire, University Bordeaux, INSERM U1034, 33600 Pessac, France
| | - Dominique Lasne
- Laboratoire D’hématologie Générale, Hôpital Universitaire Necker-Enfants Malades, AP-HP, 75015 Paris, France;
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC 27710, USA;
| | - Alain Stépanian
- Hôpital Lariboisière, Service D’Hématologie Biologique, Institut de Recherche Saint-Louis, Université de Paris, AP-HP Nord-Université de Paris, EA 3518, 75010 Paris, France;
| | - Sophie Susen
- Laboratoire D’Hématologie-Hémostase, Université de Lille, CHU Lille, 59037 Lille, France;
| | - Corinne Frère
- Department of Hematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, INSERM UMRS_1166, Sorbonne Université, 75013 Paris, France;
| | - Thomas Lecompte
- Départements de Médecine, Service D’angiologie et D’hémostase et Faculté de Médecine Geneva Platelet Group (GpG), Université de Genève et Hôpitaux Universitaires de Genève, 1205 Genève, Switzerland;
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC), CHU UCL Namur, Université Catholique de Louvain, 5530 Yvoir, Belgium;
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14
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Kanji R, Kubica J, Navarese EP, Gorog DA. Endogenous fibrinolysis-Relevance to clinical thrombosis risk assessment. Eur J Clin Invest 2021; 51:e13471. [PMID: 33296082 DOI: 10.1111/eci.13471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/05/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022]
Abstract
The development of an obstructive luminal thrombus is pathological and considered a failure of endogenous fibrinolysis. The consequences may be fatal, or result in lasting downstream organ damage. Therefore, assessment of endogenous fibrinolytic status in an individual may identify those at risk of occlusive thrombus formation and provide prognostic information. Arterial thrombi are more platelet rich and more resistant to fibrinolysis than venous thrombi. Several recent studies using global tests of fibrinolysis in patients with acute coronary syndromes (ACS) have shown that despite dual antiplatelet therapy, patients with impaired fibrinolytic status have an increased risk of adverse cardiovascular events, compared with those with effective fibrinolytic function. Such data add significantly to the predictive value of established cardiovascular risk factors and conventional biomarkers. Most data reported have been obtained with the Global Thrombosis Test and the turbidimetric plasma clot lysis assay. A few small studies in patients with ischaemic stroke suggest a similar predictive role of fibrinolytic status assessment in these patients. Studies reporting an association between impaired fibrinolysis and future venous thrombotic events are limited, and in the form of case-control studies. Viscoelastic assays may have a role in the prediction of venous thromboembolic risk. Assays of fibrinolytic function should be used to obtain a more accurate risk of future thrombotic events, particularly in the setting of ACS. The availability of point-of-care tests helps facilitate this and should encourage future studies to assess personalised antithrombotic treatment combinations to optimise fibrinolytic status and reduce thrombosis risk.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Eliano P Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK.,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Stevenage, UK
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15
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Marvi TK, Stubblefield WB, Tillman BF, Tenforde MW, Feldstein LR, Patel MM, Self WH, Grijalva CG, Rice TW. Thromboelastography Parameters and Platelet Count on Admission to the ICU and the Development of Venous Thromboembolism in Patients With Coronavirus Disease 2019. Crit Care Explor 2021; 3:e0354. [PMID: 33786433 PMCID: PMC7994046 DOI: 10.1097/cce.0000000000000354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Determine if thromboelastography parameters and platelet count on the day of ICU admission are associated with the development of venous thromboembolism in patients with coronavirus disease 2019. DESIGN Prospective, observational cohort study. SETTING Tertiary-care, academic medical center in Nashville, TN. PATIENTS Patients with coronavirus disease 2019 pneumonia and acute respiratory failure admitted to the adult ICU without venous thromboembolism at the time of ICU admission. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The primary outcome was development of venous thromboembolism during the index hospitalization. Venous thromboembolism was defined by clinical imaging or autopsy, demonstrating deep vein thrombosis or pulmonary embolism. Forty consecutive critically ill adults with laboratory-confirmed coronavirus disease 2019 were enrolled; 37 (92.5%) were hypercoagulable by at least one thromboelastography parameter at the time of ICU admission and 12 (30%) met the primary outcome of venous thromboembolism during the index hospitalization. Patients who developed venous thromboembolism had decreased measures of clotting (maximum amplitude, alpha angle, shear elastic modulus parameter, and clotting index) on ICU admission thromboelastography compared with patients who did not develop venous thromboembolism (p < 0.05 for all measures). For each individual thromboelastography parameter used to dichotomize patients as hypercoagulable, the rate of venous thromboembolism was not higher in those identified as hypercoagulable; in fact, the venous thromboembolism rate was higher in patients who were not hypercoagulable by thromboelastography for maximum amplitude (p = 0.04) and alpha angle (p = 0.001). Platelet count was positively correlated with maximum amplitude, alpha angle, G parameter, and clotting index, and significantly lower in patients who developed venous thromboembolism than those who did not (median 186 vs 278 103/μL, p = 0.046). Venous thromboembolism was associated with inhospital mortality (odds ratio, 6.3; 95% CI, 1.4-29; p = 0.02). CONCLUSIONS Our data do not support the use of thromboelastography to risk stratify critically ill adults with coronavirus disease 2019 for the development of venous thromboembolism or to guide decisions about anticoagulation. Lower platelet count on ICU admission, which may reflect platelet aggregation, was associated with venous thromboembolism.
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Affiliation(s)
- Tanya K Marvi
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Benjamin F Tillman
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Mark W Tenforde
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA
| | - Leora R Feldstein
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA
| | - Manish M Patel
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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16
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The Role of TEG Analysis in Patients with COVID-19-Associated Coagulopathy: A Systematic Review. Diagnostics (Basel) 2021; 11:diagnostics11020172. [PMID: 33530346 PMCID: PMC7911186 DOI: 10.3390/diagnostics11020172] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 12/20/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19)-associated coagulopathy (CAC), characterized by hypercoagulability and an increased risk of thrombotic complications, is an important consideration in the management of patients with COVID-19. As COVID-19 is a new disease, no standard of care for the diagnosis or management of its associated coagulopathy is yet established. Whole blood viscoelastic tests, such as thromboelastography (TEG® hemostasis analyzer), analyze whole blood to provide a complete overview of the coagulation status. We conducted a systematic review of thromboelastography for management of patients with COVID-19, using MEDLINE (PubMed) and Cochrane databases. TEG® parameter measurements and clinical outcomes data were extracted for analysis. Our review found 15 publications, with overall results showing thromboelastography can identify and assess a hypercoagulable state in patients with COVID-19. Furthermore, utilization of thromboelastography in this patient population was shown to predict thrombotic complications. The benefits of thromboelastography presented here, in addition to advantages compared with laboratory coagulation tests, position thromboelastography as an important opportunity for optimizing diagnosis of CAC and improving patient management in COVID-19. Given that the benefits of thromboelastography have already been demonstrated in several other clinical applications, we anticipate that clinical data from future studies in patients with COVID-19 will further elucidate the optimal use of thromboelastography in this patient population.
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17
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Individualised Risk Assessments for Recurrent Venous Thromboembolism: New Frontiers in the Era of Direct Oral Anticoagulants. HEMATO 2021. [DOI: 10.3390/hemato2010003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality and is associated with high recurrence rates. The introduction of direct oral anticoagulants (DOACs) in the 2010s has changed the landscape of VTE management. DOACs have become the preferred anticoagulant therapy for their ease of use, predictable pharmacokinetics, and improved safety profile. Increasingly, guidelines have recommended long term anticoagulation for some indications such as following first unprovoked major VTE, although an objective individualised risk assessment for VTE recurrence remains elusive. The balance of preventing VTE recurrence needs to be weighed against the not insignificant bleeding risk, which is cumulative with prolonged use. Hence, there is a need for an individualised, targeted approach for assessing the risk of VTE recurrence, especially in those patients in whom the balance between benefit and risk of long-term anticoagulation is not clear. Clinical factors alone do not provide the level of discrimination required on an individual level. Laboratory data from global coagulation assays and biomarkers may provide enhanced risk assessment ability and are an active area of research. A review of the prediction models and biomarkers for assessing VTE recurrence risk is provided, with an emphasis on contemporary developments in the era of DOACs and global coagulation assays.
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18
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Yuriditsky E, Horowitz JM, Merchan C, Ahuja T, Brosnahan SB, McVoy L, Berger JS. Thromboelastography Profiles of Critically Ill Patients With Coronavirus Disease 2019. Crit Care Med 2020; 48:1319-1326. [PMID: 32618696 PMCID: PMC7314320 DOI: 10.1097/ccm.0000000000004471] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The rate of thromboembolic events among patients with coronavirus disease 2019 is high; however, there is no robust method to identify those at greatest risk. We reviewed thromboelastography studies in critically ill patients with coronavirus disease 2019 to characterize their coagulation states. DESIGN Retrospective. SETTING Tertiary ICU in New York City. PATIENTS Sixty-four patients with coronavirus disease 2019 admitted to the ICU with thromboelastography performed. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Fifty percent of patients had a clotting index in the hypercoagulable range (clotting index > 3) (median 3.05). Reaction time and K values were below the lower limit of normal in 43.8% of the population consistent with a hypercoagulable profile. The median α angle and maximum amplitude (75.8° and 72.8 mm, respectively) were in the hypercoagulable range. The α angle was above reference range in 70.3% of patients indicative of rapid clot formation. Maximum amplitude, a factor of fibrinogen and platelet count and function, and a measure of clot strength was above reference range in 60.1% of patients. Thirty-one percent had thromboembolic events; thromboelastography parameters did not correlate with events in our cohort. Those with D-dimer values greater than 2,000 were more likely to have shorter reaction times compared with those with D-dimer levels less than or equal to 2,000 (4.8 vs 5.6 min; p = 0.001). CONCLUSIONS A large proportion of critically ill patients with coronavirus disease 2019 have hypercoagulable thromboelastography profiles with additional derangements related to fibrinogen and platelet function. As the majority of patients have an elevated thromboelastography maximum amplitude, a follow-up study evaluating platelet aggregation would be instructive.
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Affiliation(s)
- Eugene Yuriditsky
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
| | - James M Horowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
| | | | - Tania Ahuja
- Department of Pharmacy, NYU Langone Health, New York, NY
| | - Shari B Brosnahan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU Langone Health, New York, NY
| | - Lauren McVoy
- Department of Pathology, NYU Langone Health, New York, NY
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Langone Health, New York, NY
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19
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Evaluation of coagulation status using viscoelastic testing in intensive care patients with coronavirus disease 2019 (COVID-19): An observational point prevalence cohort study. Aust Crit Care 2020; 34:155-159. [PMID: 32773357 PMCID: PMC7373052 DOI: 10.1016/j.aucc.2020.07.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 12/17/2022] Open
Abstract
Background Coronavirus Disease-19 (COVID-19) is associated with a high rate of thrombosis, the pathophysiology of which is not well defined. Viscoelastic testing may identify and characterise hypercoagulable states which are not apparent using conventional coagulation assays. Objectives The objective of this study was to undertake viscoelastic evaluation of the coagulation state in critically ill adults with COVID-19–associated respiratory failure Methods This was a single-centre observational point prevalence cohort study of adults with COVID-19–associated respiratory failure requiring respiratory support in the intensive care unit. Coagulation status was evaluated using rotational thromboelastometry (ROTEM®) in conjunction with laboratory markers of coagulation. Results Six patients fulfilled inclusion criteria. Each patient had one ROTEM® performed. All patients had supranormal clot amplitude at 10 min (A10) and supranormal clot firmness (maximal clot firmness) measured in at least one ROTEM® pathway, and five were supranormal on all pathways. Minimal clot lysis was present on all analyses. Fibrinogen and D-dimer were elevated and routine markers of coagulation within normal ranges in all patients. Conclusion Patients with COVID-19–associated respiratory failure admitted to the intensive care unit exhibit a hypercoagulable state which is not appreciable on conventional tests of coagulation. Supranormal clot firmness, minimal fibrinolysis, and hyperfibrinogenaemia are key findings. Further research is required into the pathophysiology of this hypercoagulable state, as well as the harms and benefits of different anticoagulation strategies.
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20
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Incidence of Antithrombin Deficiency and Anti-Cardiolipin Antibodies After Severe Traumatic Brain Injury: A Prospective Cohort Study. Neurocrit Care 2020; 34:227-235. [PMID: 32557110 DOI: 10.1007/s12028-020-01026-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Animal studies suggested that cerebral mitochondrial cardiolipin phospholipids were released after severe traumatic brain injury (TBI), contributing to the pathogenesis of thromboembolism. OBJECTIVES To determine the incidence of anti-cardiolipin antibodies after severe TBI and whether this was related to the severity of TBI and development of venous thromboembolism. METHODS Serial anti-cardiolipin antibodies, antithrombin levels, viscoelastic testing, and coagulation parameters were measured on admission, day-1, and between day-5 and day-7 in patients with severe TBI requiring intracranial pressure monitoring. RESULTS Of the 40 patients included (85% male and median age 42 years), 7 (18%) had a raised Ig-G or Ig-M anti-cardiolipin antibody titer after TBI. Antithrombin levels were below the normal level-especially on day-0 and day-1-in 15 patients (38%), and 14 patients (38%) developed an increase in maximum clot firmness on the viscoelastic test in conjunction with elevations in fibrinogen concentration and platelet count. Four patients (10%) developed deep vein thrombosis, and 10 patients (25%) died, both of which were not significantly related to the presence of anti-cardiolipin antibodies (P = 0.619 and P = 0.638, respectively). CONCLUSIONS A reduction in antithrombin level and development of anti-cardiolipin antibodies were not rare immediately after severe TBI; these abnormalities were followed by an increase in in vitro clot strength due to elevations in fibrinogen concentration and platelet count. The quantitative relationships between the development of anti-cardiolipin antibodies and severity of TBI or clinical thromboembolic events deserve further investigation.
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Abstract
OBJECTIVES Critically ill patients with deranged conventional coagulation tests are often perceived to have an increased bleeding risk. Whether anticoagulant prophylaxis for these patients should be withheld is contentious. This study assessed the ability of using in vitro clot strength, as measured by thromboelastography, to predict thromboembolism in patients with abnormal coagulation profiles. DESIGN Prospective cohort study. SETTING A tertiary ICU. PATIENTS Two-hundred and fifteen critically ill coagulopathic patients with thrombocytopenia and/or a derangement in at least one conventional coagulation test (international normalized ratio or activated partial thromboplastin time) within 48 hours of ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thromboelastography was performed for all study patients, and plasma thrombotic biomarkers were measured in a nested cohort (n = 40). Of the 215 patients included, 34 patients (16%) developed subsequent thromboembolism-predominantly among those with a normal (maximum amplitude, 54-72 mm) or increased (maximum amplitude, > 72 mm) in vitro clot strength on thromboelastography (91%; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.64-0.83). The ability of the maximum amplitude to predict thromboembolism was comparable to plasma P-selectin concentrations (thromboembolism, 78.3 ng/mL vs no thromboembolism, 59.5 ng/mL; p = 0.031; area under the receiver-operating characteristic curve, 0.73; 95% CI, 0.52-0.95). In addition, patients with an increased maximum amplitude were also less likely to receive blood product transfusions within 24 hours of testing compared with those with a subnormal maximum amplitude (12.8% vs 69.2%, respectively; area under the receiver-operating characteristic curve, 0.74; 95% CI, 0.67-0.80). CONCLUSIONS In patients with abnormal coagulation profiles, an increased in vitro clot strength on thromboelastography was associated with an increased risk of thromboembolism, and a reduced risk of requiring transfusion compared with those with a normal or reduced in vitro clot strength.
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22
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Jud Schefer R, Heimgartner L, Stirn M, Sigrist NE. Determination of reference intervals for single vial rotational thromboelastometry (ROTEM) parameters and correlation with plasmatic coagulation times in 49 clinically healthy dogs. Res Vet Sci 2020; 129:129-136. [PMID: 31982776 DOI: 10.1016/j.rvsc.2020.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 01/05/2023]
Abstract
The objectives of this prospective study were determination of reference intervals (RI) for rotational thromboelastometry (ROTEM) parameters in single use reagents and to evaluate correlations between plasmatic coagulation times and ROTEM parameters. Blood was sampled from a jugular vein in 49 client-owned healthy dogs and ex-tem S, in-tem S, fib-tem S and ap-tem S parameters, prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, haematology, blood chemistry and venous blood gas analysis was performed. Determination of RI was performed using Excel add-in Reference Value Advisor and correlations between PT, aPTT and fibrinogen with selected ROTEM parameters were determined by Spearman correlation. Ex-tem S maximum clot firmness (MCF) RI are smaller compared to RI in people and liquid ex-tem in dogs while maximum lysis was comparable to those in people but smaller than previously reported in dogs. A strong correlation was found between fibrinogen measured by Clauss and fib-tem S and in-tem S MCF (r = 0.541, P < .001 and r = 0.610, P < .001, respectively). PT showed a significant but moderate correlation with ex-tem S CT (r = 0.340, P = .030), in-tem S CFT (r = 0.433, P = .003), fib-tem S CT (r = 0.426, P = .009) and ap-tem S CT (r = 0.354, P = .015) while aPTT was not significantly correlated with any of the evaluated parameters. In conclusion, this study provides single use reagent ROTEM parameter RIs that are different from RI determined with liquid reagents. Significant correlations between fibrinogen concentrations measured by Clauss and clot firmness of fib-tem S and in-tem S profiles and between PT and clotting times of all reagents were identified.
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Affiliation(s)
- Rahel Jud Schefer
- Division of Emergency and Critical Care Medicine, Department of Small Animals, Vetsuisse Faculty of the University of Zurich, Switzerland.
| | - Lara Heimgartner
- Division of Emergency and Critical Care Medicine, Department of Small Animals, Vetsuisse Faculty of the University of Zurich, Switzerland
| | - Martina Stirn
- Clinical laboratory, Department for Clinical Diagnostics and Services, Vetsuisse Faculty of the University of Zurich, Switzerland
| | - Nadja E Sigrist
- Division of Emergency and Critical Care Medicine, Department of Small Animals, Vetsuisse Faculty of the University of Zurich, Switzerland.
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23
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Saseedharan S, Talla VB, Chiluka A. Thromboelastography Profile of Patients with COVID-19 Admitted to Intensive Care Unit: A Single-center Retrospective Study from India. Indian J Crit Care Med 2020; 24:1218-1222. [PMID: 33446976 PMCID: PMC7775920 DOI: 10.5005/jp-journals-10071-23675] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Coronavirus disease (COVID-19) causes thromboinflammation resulting in a high incidence of venous thromboembolism (VTE) events, which occur in significant numbers despite giving standard thromboprophylaxis with low-molecular-weight heparins. Various markers and tests have been evaluated and found to have a strong association with the worse prognosis of the disease. Common coagulation markers like D-dimer and fibrinogen give more of a static picture of coagulation, whereas viscoelastic tests like thromboelastography (TEG) provide an understanding of the coagulation function and help in better interpretation. We conducted a retrospective analysis of TEG values of 32 patients with COVID-19 admitted to the intensive care unit (ICU). Hypercoagulation as defined by TEG-coagulation index (CI) higher than the upper limit of the normal reference range (NRR) is found in 62.5% of the patients. There is also a clear representation of hypercoagulability as reflected by TEG-R, TEG-K, and TEG-LY30 values lower than or toward the lower limit of NRR, and TEG-ANGLE, TEG-MA, and TEG-CI values higher than or toward the upper limit of NRR which is more pronounced in severe forms of the disease, both in comparison to NRRs and other non-COVID ICU patients. Findings are similar to that of earlier studies in patients with COVID-19 except for the LY30, which is retained in the majority of our patients. Thromboelastography can be a useful tool to understand and screen for COVID-19-related hypercoagulability and may help predict VTE events. The potential of TEG to determine the optimal anticoagulant therapy needs to be evaluated in larger prospective studies. How to cite this article: Saseedharan S, Talla VB, Chiluka A. Thromboelastography Profile of Patients with COVID-19 Admitted to Intensive Care Unit: A Single-center Retrospective Study from India. Indian J Crit Care Med 2020;24(12):1218–1222.
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Affiliation(s)
- Sanjith Saseedharan
- Department of Intensive Care Unit, SL Raheja Hospital, Mumbai, Maharashtra, India
| | - Vijay B Talla
- Department of Pharmacology, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
| | - Annapurna Chiluka
- Department of Intensive Care Unit, SL Raheja Hospital, Mumbai, Maharashtra, India
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Fibrinography: A Multiwavelength Light-Scattering Assay of Fibrin Structure. Hemasphere 2019; 3:e166. [PMID: 31723805 PMCID: PMC6745935 DOI: 10.1097/hs9.0000000000000166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 11/20/2018] [Indexed: 02/06/2023] Open
Abstract
We have previously developed a fibrin structural assay dedicated to purified fibrinogen-thrombin system. Here, we extend the pertinence of this test, called Fibrinography, to tissue factor-triggered plasma coagulation. We show that Fibrinography determines quantitatively the structure of fibrin fibers in plasma with an excellent reproducibility. We compare this assay with the commonly used single wavelength turbidity method, showing that the latter is not a proper structural assay, but determines essentially the fibrinogen content in plasma. In addition, we also show, in model plasmas, that Fibrinography is able to discriminate normal and hypocoagulant plasmas, and even between hypercoagulant plasmas. Therefore, Fibrinography, by measuring the final step of the coagulation cascade, may be used to evaluate patients’ plasma in hypo- or hypercoagulant diseases.
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